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AUG-19-99 THU 03 :28 PM FOGIH1Lt l_IY4aylyCCrS11�La �-- <br /> Off OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> Coma APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> 0 <br /> pApppicanrs <br /> Name_ �_��--I' t L•l•" _E L]" I ata -4-4 <br /> {Opn-r=nlracror) <br /> - PYre LuAPPROV )ad nss PUBLIC WORKS DIRECTOR State <br /> — <br /> — —`'�' <br /> Locawn of Proposed Work etc. —�i � --OF Lj; 'Fp L <br /> 3p-fTF . Galt 2 ,A k <br /> Dale <br /> Owner!Cal[rartor Address � — ��TTTT�� <br /> Com iieNen Data �_ PermitExpiration Date -- <br /> Estr-etag starting Date - --- — - <br /> - PT <br /> I(or We)herebyapply for an enroachment permit to carry out a lowing A h <br /> The above named applicanl herebymquesis pe <br /> rm <br /> �''�'' �+ ( �•�issionto- PERMIT FEE.........................................��_ <br /> EA 1 r I- `t r _J A46tional Footage Fee..........................f <br /> Sewer Tap Deposit............................. <br /> _. _ <br /> TOTAL DEPOSIT.._....., <br /> Building Permit No_ <br /> Improvement Plan No, <br /> Supplemental Conditions-. <br /> Show sketch above at rater to drawing Svbm,ltad <br /> IMPORTANT. Applicant hereby agrees to comply with an 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 indemnity 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 (t-BW642-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL(209) PRIOR TO START OF WORK FOR A CONTROL NUMBER AND T4 SmEDULE <br /> INSPECTION. <f&h 48 fiCUIZ5 <br /> Read General Provisions on reverse side of s per befo signin - Note requirement of notificationnsr/��and inspections. <br /> -- Mone: 366..—T391 -- <br /> +81-Pa"iltoe 2ndFila 3M Fiance 4ib UGliyM1*e( <br />