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I <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicants Nome �12(�J!'OIiCS'ct/Tpate 60184 <br /> (Owner/Contractor) <br /> Addres:.tl���� �xs�Jc+`. Pho(.!-',4 3 <br /> Location of Proposed Work, c.. ��a)�"�'I Sax .S'>r. AXC� <br /> "n APPROVED: DIRECTOR OF PUBLIC WORKS <br /> eetc <br /> 1�rr (/[�Cr <br /> Owner/Contractor Address B p Date v <br /> Estimated Starting Dotes4az_1( Completion Date '(��w/ Permit Expiration Date lj--q/' <br /> I (or We) hereby apply for an encroachment permit to carry out the following work:_1 r2ST- 111 O <br /> The above named applicant hereby requests permission to. PERMIT FEE................................................ f <br /> Additional Footage Fee_. ... .... ..._.._ <br /> Sewer Tap Deposit .................................... 2Q <br /> TOTAL DEPOSIT ........................ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: _ <br /> l <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, <br /> resolutions, standards and specifications currently in effect, and to pay to City its actual cost for removal and proper replace- <br /> ment of any item which does not meet above requirements. Failure to comply will be cause for revocation of permit. Appli- <br /> cant agrees to indemnify and hold the City harmless against any and all losses, costs, or damages resulting from injury to <br /> persons, death of person or damage to property occurring at the site of or as a result of work to be performed under this <br /> permit. Certificate of insurance will be presented by applicant upon request. <br /> Read General Provisions on reverse side of this permit before signing. *Note requirement of notifications and inspections. <br /> Permit Engineer/Inspector <br /> 94+I99W <br /> 944.8366 Signed: �� Phone q/c O <br /> 1st—Permittee 2nd—File 3rd—Finonce 01'".—Utility/Street <br />