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C0AW <br /> CITY OF STOCKTON 6 4 J 195 <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Ap phCanCi Name <br /> (Ownor/Conh'actor) L L �I- <br /> -� d <br /> Address;U01 l f,�cb �1D�kl R`� Phone <br /> APPROUEO: PUBLIC WORKS DIRECTOR <br /> lOC^^ihOn Of Propos¢d Work,etC r'rrNLM t S3 eor+i p*'� Jac` ' "'_._. <br /> Ile 1b r <br /> Owner/Coniractor Address bq�f'� . .. �1p—�8Y Uat¢ 6Lup—d ----- <br /> Estimated Starting Dat® -.3/21 l r 77Comptchon Dais - + -- Permit Expiration Oatc <br /> I (or We) hereby apply toy an encroachment permit to carry9 out the following work:p :. �^ py _�- 7 <br /> S' P7- <br /> 4A. opt�TC/►C ee��v_d`at, <br /> b i r% iP g .vi A L"� <br /> I alp <br /> j"t <br /> The above nefhBd licant h8roby r "este oerrmsa+on to- ' <br /> R��P°4 PERMIT FEF... <br /> j� Addit onal Foot2ge Fel <br /> ' Sewer Tap G®pnaic ..... -...... _...._-.. <br /> r TOTAL DEPOSIT <br /> r ► papas Building Permit No.1.10 <br /> Cmprovement Plan No. --_ <br /> L -- <br /> I , Supplemental Conditions: <br /> I I r,ror•»� � �0�1 k�x•� �oc��.w1S d.1�, <br /> Show alt'eh abeve or rrry to drOvnn�Su eh716d+ <br /> IMPORTANT:Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, resolunons, <br /> standards and specifications currently in effect,and to pay to City its actual cost for removal and proper replacement of;inn itern,,vhieh <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,or damages resulting from injury to persons,death of person or damage to prciparty <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. Z <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-9002444) TWO WORKING DAYS BEFORE CEGINNINn- <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL(209)937-6411 24 HOURS PRIOR M START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. <br /> Read General provisions on reverse side of this permit <br /> before signing — Note requirement of notificatio <br /> n <br /> s Iand onps�pec.tions. <br /> 171—P—11cc Znp—File 3rd--FlM1anCB allyUh�dyi8tf08i i! <br /> d S3 SNOSddd LJd62:0T L6, 92 bdw <br />