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CITY OF STOCKTON <br /> OOA DEPARTMENT OF PUBLIC WORKS 65536 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name dei l kJ L L- F&I U (Date <br /> (Owner/Contractor) <br /> Address Z,J!7 Z Ap Cot• L u Phone 6 v <br /> City L,071:>, State (`-A Zip �I6240 APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed Work,etc. im rt 4/r-- AS 1 Co 2/V iZ <br /> Owner/Contractor Address gy t R Date <br /> Estimating Starting Date I9 Completion Date Permit Expiration Date J <br /> I (or We) hereby apply for an enroachment permit to carry out the following work: �1Zi L_i_. U �� G 1 T� <br /> i ► J 1 V4 E S ;1T -,�a yJJ0 Lor::: L-i'��A�;T- -ST. uOrZ-n-) � �UF <br /> 4Z) ' <br /> The above named applicant hereby requests permission to- --- <br /> 1 <br /> PERMIT FEE..........................................$ <br /> jC-7 A T T Additional Footage Fee...........................$ <br /> Sewer Tap Deposit................................. <br /> TOTAL DEPOSIT .............$ <br /> Building Permit No. <br /> Improvement Plan No. <br /> I <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, 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�-24-I-191�R PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. (4---37&* 4-8 QRS <br /> Read General Provisions on reverse sideof Is per befo signin - Note requirement of notifications and inspections. <br /> Signed: Phone: .:?6A <br /> 1st-Permittee 2nd-File 3rd-Finance 4th-Utility/Street <br />