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Jul 17 01 04: 20P C.i' ty of StocktonPW-Permit 12091937-13901 1°• 1 <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS 65874 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> AQ <br /> isNama 1 <'Cc: P1_14&cTs 6 i-ny Date 712-GU <br /> ner 'tractor) r <br /> Address 1006o,- S 0 77 Phone I tt676-5,)(' <br /> —State City <br /> J�ue-t" Ac'!f,! - G Ale Tip 944A -S`�7T APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed Work,etc.L �}_. <br /> 6y Alpiiiy. _t _L!t!1'ILrtcavt S4. fLl� J <br /> Owner!Contractor Address _dd i3n1 ) 13V Date <br /> Estimating Starting Date {f >! ?C.<c Completion Date._4-1�l armit Expiralign Date <br /> I (or We)hereby apply for an enroachment permit to carry out the following work: l n s i I/ /)7 r r 7- - c we I/ _ <br /> f n SKIeC,c��k <br /> .T Post-It°Fax Note 7671 Date aof t <br /> TO From <br /> i <br /> Co.lDept. Co. <br /> r <br /> Phone# Phone# <br /> i <br /> _ Faz# � Fax <br /> The above narnedappicant r Mpg J <br /> R <br /> 7� permrsswn v- PERMIT FEE..........................................5 /A 4'i'e <br /> 'i'[ RTlar k c A t1/Orel n� <br /> Additional Footage Fee...........................$ <br /> 1'J r !J d r',rr k��• a: Sewer Tap Deposit <br /> TOTAL DEPOSIT.............$ <br /> Building Permit No. : <br /> { <br /> Improvement Plan No. <br /> r <br /> Supplemental Conditions: 1 <br /> ' ! + • .,.- '', '^L�- 1.] �0 4 a�,� G ld��C..c rQ S 37+'�Y+n i r�- til. <br /> lV w:F' all cdr,Srkn.,C <br /> ` vim- 00 <br /> Show sketch above or refer to drawing sulm,tied <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 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 (1-800-642-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUq p.UTILITIES. <br /> PERMITTEE SHALL CALL(249)937--e+ - 4•HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. <br /> Read General Provisions on reverse side of i e I efore signing - Note requirement of notifications and inspections. <br /> Sign ' 4� �1 PhoneS3� 676•-4000 <br /> 15t•t'ptmltlee F ,3rd•Fnpnce <1h-Uti7iy15treat <br />