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CITY OF STOCKTON I +. <br /> 011WDEPARTMENT OF PUBLIC WORKS -•� 6 j 3 Y3 <br /> a APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> PR 2 1 ISSN <br /> A pricant's Name f Date 1 ivV1 -iUtNMF*,.'TX- Ht.r\L.Tl- <br /> {Owner/Contractor) <br /> fit 1 0FR"•0'lT ! S ir-I:�V�`C�S <br /> Addres i Phone x121-2-�S <br /> City Gt State zip 5 7/ APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed work,etc. <br /> Owner/Contractor Address By Date <br /> Estimating Starting Date Completion bate 1 —*—Permit Expiration bate <br /> (or We) hereby apply for an enroachment permit to carry out the following work: k \LL <br /> t )�� �- `7.., <br /> ti1Lt .� y+ <br /> ALA' f I ,,I <br /> The above named appticant hereby requests permission to- <br /> PERMIT FEE..........................................$ <br /> Additional Footage Fee...........................$ <br /> Sewer Tap Deposit................................. <br /> TOTAL DEPOSIT .............$ i <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> —71 <br /> 4��"C"�A1+c.� ?,�� tea•-t�, �'�:�'n -Ct'�r �,�r_1ct��+l: 1...x'�ft'��i.. ��'. `�j<L <br /> Ski w sket above or ret r t drawing submitte <br /> C`C.. C l S <br /> IMPORTANT; Applicant hereby agrees 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 the <br /> City harmless against any and all losses, costs, or 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 City <br /> Risk Manager prior to beginning construction. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800-642-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL (209)937-8411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. <br /> Read General Provisions on reverse side of t 's permit before si 6i g - Note requirement of notifications and inspections. <br /> I <br /> i <br /> 1st-PermRtee 2nd-Fite 3rd-Finance 4th-Ufi1ity1Streel <br />