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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-0F-WAY <br /> (�(?�{A /�j�)�{ N° 61573 <br /> Applicant's Name_ p�V` ��/�/Date "I�� I ' <br /> (Orwwr�ContractZ�'r I f i �( _ L D/`"^� /Cf <br /> Address_ 'Cr►`etA -phone ib �31 <br /> 1( �`y�� ��� A ROVED: DIRECTOR OF PUBLIC WORKS <br /> Location of Proposed Work,etc 1 <br /> Owner/Contractor Address <br /> -t,cRot <9AL .AM1>3Y�a 2 Ck B Date A* 2-C/— <br /> ^7 <br /> Estimated Starting Date —51I Completion Dote I_ r—� I Permit Expiration Date �z 3 9 <br /> 1 (or We) hereby apply for an encroachment ppermit to carry out the following work: <br /> MO0`7-0?_4U-)I--- lrQ tQA.-iV p R—tl GE - - <br /> The above named applicant hereby requests permission to- PERMIT FEE................................................ ZO 6 <br /> Additional Footage Fee..-- ..... ... ............. <br /> Sewer Tap Deposit .................................... <br /> TOTAL DEPOSIT ........................ = Z 0 OJ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <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 EngineerlInspector <br /> 944-8250 Coll/-)444--g <br /> 944.8388 Signed: Phone <br /> I <br /> I <br /> Ist-Permittee 2nd—fiie 3rd—Finance 4th—Utility/Street <br />