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JAN--09-1996 15:40 PUBLIC WORKS PERMIT CENTR 209 937 9901 P.02 <br /> 0 <br /> CITY OF STOCKTON 64783 <br /> REPARTMENY OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> ,+ Q <br /> Appllcanrs Namef. _ Date !- <br /> (OwnerlCantrattarj t � �Jr~,'r� <br /> 0�-?I PhoneSL. <br /> r^ APPROVEt]: PUBLIC WORKS DIRECTOR <br /> t-nestlon of Proposed Work. ater. <br /> ` �1 <br /> a aL,A �et 7 h f T r,� �{�s f� ✓k.1ex ' ht f7tG!� � <br /> Ow- nerlConlrfctcr Addrers ,1LrGt� -_--- BY <br /> Estimated Starting Date 1 I! 1$ carnMeaan Data -14—&—-- Permit Expiration gate 2 L - <br /> I (or We) hereby apply for an encroachment permit to carry out the following work_ . �'"-,n-'-f br,r r4 <br /> q n c ty n ts.ti �t -D i I I.C 1+-04'11 <br /> --max �"___,-t.�-n I�•t� ,� """` b -r + .� � _ � ..— <br /> -!.V- defiJ, <br /> r]r <br /> �c•#— �as t�-I <br /> ] -y <br /> 6u 4 l 4R oKaL�a mss@., u rt-"�'-y--� -•-- - <br /> • T"above named aPPRcem h*wehy re"sis permk.*kn to PERMIT FEE.... ............... --- <br /> Addiliortat Fnatage Fee....... <br /> Sewer Top 4epwh ................ ► -- <br /> TOFAL DEPOSIT s_—_�� <br /> Building Permit No. <br /> Improvement Plan No. ._— <br /> + (] I ,.#-23 Supplemental Conditions, <br /> SLC' P---r- �,.ta`-C -'S't►tvti� <br /> i' <br /> Show sketch sbure of rater to drawihQ dubmh0d <br /> IMPOF17 ANT Applicant hereby-agraes to comply with all provisions of this permit as well as all applicable City ordinances, resolutions, <br /> standards and specifications currently in effect,and to pay to City its actual cost for removal and proper replacement of any item which <br /> does not meet above requirements. Failure to comply will be cause for revocation of permit. Applicant agrees to indemnify and hold <br /> the City harmless against any and all losses,costs,er damages resulting from injury to persons,death of person or damage tO property <br /> occuring at the site of or as a result of work to be performed under this permit. A certificate of insurance shall be submitted to the <br /> City Risk Manager prior to beginning construction. (4� <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-S00-'DQ-2444) TWO WORKING DAYS BEFORF BEGINNING <br /> WORK rOR LOCATION Or UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL(21)0)937-8411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCKEDULE <br /> INSPECTION. <br /> React General Provisions an reverse side of this permit before signing — Note requirement of notifications and inspections. <br /> 1M.-Pcrmisec <br /> an�F tic 3r#-Finanr_c a th--�rility 7 Slrnel <br /> TOTAL P-02 <br />