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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS 65874 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Ago <br /> p�y�anrsName 100—C40 pl-.0du-1-T-5 C. Ort Date 7-12`0e) <br /> caner ontractor) <br /> Address P19 Qo SO 77 Phone 7I Y 670 330.3 <br /> 13 �" �^ State Irf zip gDLAZ S'977 APPROVED: PUBLIC WORKS UIRECTOFt <br /> City (ze <br /> Location of Proposed work,etc. 3AOQ <br /> Owner/Contractor Address nn By Date <br /> Estimating Starling Date �!u ` 2 d 0,51 Completion Date Permit Expiration Date <br /> I (or We) hereby appiy for an enroachment permit to carry out the following work: 117 S I�/f ryT oar !� ted c 1/ <br /> 1 <br /> The above named applicant hereby requests permission to- l g Cp <br /> ��7j -1 PERMIT FEE..........................................$ <br /> ,S F it !-t 7T--c/LaAr�r!1tJ f�t5 <br /> Additional Footage Fee........................... <br /> ul ell deo 1, a S.Y 4 a 5 Sewer Tap Deposit................................. <br /> TOTAL DEPOSIT .............$ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> 1 <br /> Show sketch above or rater to drawing submilted <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=5444HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. 5-�Wa i <br /> Read General Provisions on reverse side of hi e t More signing - Note requirement of notifications and anct inspections- <br /> Signed: !qr, Yk Cr' YI of D PhonS-Pt676 K000 <br /> Aih-UtilitylStreet <br /> V-Permittee nd-F' 3rd-Fin3nce <br />