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• <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Nam Date v �' 55718 <br /> (Owner/Contract s <br /> AddressPh e <br /> APPROVED: DIRECTOR OF PUBLIC WORKS <br /> Location of Proposed Work,etc. <br /> Owner/Controctor Address By Date Date —� 7 <br /> Estimated Starting DateCompletion Date "nn,-(o p1 -Permit Expiration Date (0-2�1 <br /> I for We) hereby apply for an encroachment permit to carry out the following work: <br /> The above named applicant hereby requests permission to - <br /> PERMIT FEE ._...................._....._....._._..._. E <br /> Additional Footage Fee_. __ _. .... .._.. <br /> Sewer Tap Deposit ........................-.......... <br /> TOTAL DEPOSIT ........................ E C� <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Show sketch above or refer to drawing submitted <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, <br /> resolutions, standards and specifications currently in effect, and to pay to City its actual cost for removal and proper replace- <br /> ment of any item which does not meet above requirements. Failure to comply will be cause for revocation of permit. Appli- <br /> cant agrees to indemnify and hold the City harmless against any and all losses, costs, or damages resulting from injury to <br /> persons, death of person or damage to property occurring at the site of or as a result of work to be performed under this <br /> permit. Certificate of insurance will be presented by applicant upon request. <br /> Read General Provisions on reverse side of this permit be a signing. ,*Note requirement of notifications and Inspections. <br /> Permit Engineer/Inspector <br /> 944.8492 <br /> 944.8386 Signe Phone <br /> 1st—Permittee 2nd-4ile 3rd—Finonce 4th—Utility/Street <br />