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.10126/2001 11:39 2094671118 AGE STOCKTON PAGE 02 <br /> CITY OF STOCKTON % -7, <br /> PUBLIC WORKS DEPARTMENT 0 ' t <br /> xx <br /> APPLICATION-FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Appticanl s Name }cIy�GA t(1 �eRse to APPROVED:B P LI IRECTDR <br /> (Owner/Contracliur; <br /> 1 ,__ `` �,{,� T Q Srb;ekt to the PaAr► aril and a6 <br /> Addro�s �}�p���VbA . shone.�`� taodc must oontt7rm s apprevred Strum Waler Ibputi0r <br /> %7tY S6 lac&& State CA dip Prevention Men Prevention Mokrt r the Wty of r <br /> fIcIbAun <br /> Ids,whicnever is applicabfe. <br /> Location of Proposed Werk etc_ Q <br /> Owner,`Contractor Address _— Sy �� �� —Date <br /> Estimating SW"Date_ sa.IT_�-qr t�o k ComplEtlor Daw -_�4yy%Q ...—Permit Expiration -- <br /> I for We) hereby apply`or an Encroachment Permit to carry out the following work <br /> +IA A . IV r <br /> Ae <br /> -* <br /> _ <br /> TV*above rymed appbobrrt harebrr tdqueds p mda6m b- �7 r/ <br /> P£RMft'FEE ................. $ <br /> Additional Footage Fee..... ...._ *� <br /> j Trench Fee S 't►` <br /> Sewer Tap Do osit..........,_._.:...S <br /> I <br /> a� <br /> TOTAL DEPOSIT.........;! _ <br /> Building Permit No. <br /> Improvement Plan No <br /> Supplemental Conditions: <br /> b7gw*qY h Qd rn or rplar(o dawwrg sLdmn od <br /> IMPOR'T'ANT 4pplicent hammy agrees to comply with all provisions of this perrrut,as well as all applicable tarty ordinAnces,resquliturs, <br /> Standards and Spedfcallons currently in effect,and to pay to the City Its actual cost for rernovei and proper replaoament of any hem whlch doss <br /> not meet the above raqulramonts Fallure to comply will be rause for revocation erl pem*AppOmnt agrees to Indemnity and hold the City <br /> heirrdess against any and all losseb,costs,or damages resuning from injury to persons,death of person or damage to property occurring at the site <br /> ef,or as a result of,work to be performed under this permit A certificate of insurance shall be submittad In the City Risk Manager prior to lssuanee <br /> of tits permit <br /> FERIdTTEE SHALL CALL(209)937-8996 FOR A CONTROL_NUMBER NO LESS THAN 24 HOURS,DLrr NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE START OF WORK.AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE 81 DE OF THIS <br /> PERMIT_IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTRGIL NUMBER.THE CONTROL NUMSER WILL <br /> BECOME INVALID AND THE PERMITTER`SHALL CALL FOR A NEW roNTROL NUMBER-(FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SURDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNFD CITY PROJECT ENGINEER AT(209)937-8411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BE13INNINO OF ANY WORK_) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF Tlyg PER RE SIG"ING. h <br /> Signed {—� — <br /> Phone—of <br /> ist-r errWrtes(whits) 2rxi-1repecelon(pIrN ( and-Flle(yetIvM 471+'kmnce fv"*) <br /> t Y:11 1111A 1 iso <br />