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II X367 t <br /> CITY OF STOCKTON <br /> PUBLIC <br /> DEPARTMENT OF PUBLIC WORKS <br /> Aa# APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> rr <br /> it <br /> r Applicant 's Name l/G <br /> (Owner/ ContraClo <br /> Address / • _ yt� T`/f/ltkl� 3LC --- Phone /ji7J J Zyf <br /> I I t APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed Work, etc. <br /> Owner/ Contractor Address, "_ �yy ______._._. __— —.. _. . _.._ _ - By _..qaoomb <br /> + _ Dale___ <br /> Estimated Starting Dale ez. 042d` �—.... _ Completion Dale L��, t• ��ij_� Permit Expiration Date —J <br /> I (or We) hereby apply for an encroachment permit to carry out the following work <br /> _!c <br /> The above named applicant hereby requests permission to PERMIT FEE . . . . . . . . . $_ __ _ �� V--- — - <br /> Additional Footage Fee . . . . . . . . . . . . . <br /> Sewer Tap Deposit . . . . . . . . . . . . . __ ..__.. _ <br /> TOTAL DEPOSIT . . . . <br /> . . . . . $__ _ - <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Show sketch above or rotor to. drawing submilted r <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 <br /> the 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 tothe <br /> City Risk Manager prior to beginning construction . <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800-842-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL (209) 937-8411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION . <br /> Read General Provisions on reverse side of this permit )before s'gmng — Note requirement of notifications and inspections. <br /> q.L /,,n <br /> Phone. .�r'�� � y� <br /> j., <br /> pd—Permittee. 2nd File 3rd.—Finance •IIs—Ulihty l Street <br />