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C <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name eiy Date _. � 55855 <br /> (Owner/Contr ctor) Phone <br /> Addres � // <br /> APPROVED: DIRECTOR OF PUBLIC WORKS <br /> Location of Proposed Work,etc. y/C��"i OT �•Y <br /> ,A/ _o/ <br /> Owner r By4Date <br /> OTT <br /> Estimated Starting Date / Completion Date 2 Permit Expiration Date <br /> I (or We) herebyapply for n encroachment permit to carry out the following work: <br /> The above named applicant hereby requests permission to - PERMIT FEE ................................................ $ <br /> Additional Footage Fee... . .... .. ._......._. <br /> Sewer Tap Deposit .__............................... <br /> TOTAL DEPOSIT ........................ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> ll�ri�Ns ON �P��oc`'ab/e <br /> e11111 7/-- <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 before signing. 'Note requirement of notifications and inspections. <br /> Permit Engineer/Inspector <br /> 944.8492 I/ <br /> 944.8366 Signed: L�C.CJfPhone <br /> 1st—Permittee 2nd—File 3rd—Finance 4th—Utility/Street <br />