Laserfiche WebLink
CITY OF STOCKTON <br /> WPDEPARTMENT OF PUBLIC WORKS U <br /> QA APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Aa# <br /> Applicant's Name lm."WAWL ��L-,V I�Q w1�✓� - _ ate _ Z �e a <br /> (Owner/Con��tracctntoq � 1q <br /> Address � N W l�S O liA �� (1 n Phone (4(01 - 0 4 <br /> l _ I APPROVED: PUBLIC WORKS DIRECTOR <br /> City 1ttJC-k�9y\. State -s,� Zip I iF-Z <br /> Location of Proposed Work,etc. S Nc" Mn >- S-�(2�QT �W\- <br /> 7101 L. c." �e� <br /> Owner/Contractor Address _ _ Date <br /> Estimating Starting Date Completion DateermDate <br /> I (or We) hereby apply for an enroachment permit to carry out the following work: OX-\4L <br /> V1p✓► -,.100 �O c),,SC.�G s �f ` w <br /> ' The above named applicant hereby requests permission to- <br /> PERMIT FEE..........................................$ CZ �✓�_ <br /> Additional Footage Fee...........................$ <br /> Sewer Tap Deposit................................. i <br /> TOTAL DEPOSIT.............$ `. <br /> Building Permit No. <br /> z ; k J Improvement Plan No. <br /> --� �y [� Supplemental Conditions: <br /> i� <br /> � kipiv?cz. <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 UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL (209) 937- 1 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. �7(� <br /> Read General Provisions on reverse side of th permit before signing - Note requirement of notifications and inspections. <br /> r <br /> signed: 2.,i- Phone: `v <br /> '.st-Permittee 2nd-File 3rd-Finance 4th-Utility/Street <br />