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CITY OF STOCKTON _""Old <br /> 467 DEPARTMENT OF PUBLIC WORKS 6 5 U T 4 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Ago <br /> &DWLQnt's Ai'C66!! eimx' Date 7.12-00 <br /> OVme ontractor) <br /> Address F0 eo,< D 7T Phone 7/y670 6S)o3 <br /> City 3"'e �4 sir State APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed Work,etc. <br /> - ;�'_�y` <br /> Owner/Contractor AddressQ � B Date <br /> Estimating Starting hate +��' 2 bOo Completion Date I' e__ —4� ermit Expiration Hate E <br /> I (or We)hereby apply for an enroachment permit to carry out the following work: /17,5--// /P?on f lv I�L5 We <br /> The above named applicant hereby requests permission to- <br /> 3 a e I�TJ�c Ec �tw r KS PERMIT FEE..........................................$ <br /> A e1 <br /> --� o-F mo � Additional Footage Fee...........................$... ao ,�� <br /> W ell d e).3 bL 5�7e' Pt 4%.-5 O Sewer Tap Deposit................. <br /> TOTAL DEPOSIT .............$ F G� <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> '2-0'?1aC aa,tt/ daW4X4zZ1 - ►c�r� �l�. <br /> A-L,J t <br /> �L>'hl7ltr �� 3l1 <br /> l CkfC 0 -��q <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 UNDERGROUNS UTILITIES. <br /> PERMITTEE SHALL CALL (209)937--8444-U HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. M& <br /> Read General Provisions on reverse side of hi e I efore signing - Note requirement of notifications and inspections. <br /> Signed: A C .1 •✓ U Phan , L^ /C✓-��CJ <br /> t st-Permittee nd-F' 3rd•Finance 4th-Utility/Street <br />