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63745 <br /> CITY OF STOCKTON V <br /> DEPARTMENT OF PUBLIC WORKS �II�j <br /> Aa# APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WA LL�� <br /> /� <br /> DEC o 7 1995 <br /> Applicant's Name A& fr� Grn�,.y,s-ti,1rP4 Nr l— Date 1Z ' 9 <br /> (Owner!Cont ractor) <br /> Address—��Q3—1ra� QC.Ic�.._-.} _., 47+� &- Phone FNS "*W <br /> APPROVED: PU <br /> Location o1 Proposed Work,etc. <br /> 146 W. -AAar>liNwm A-ZI <br /> Owner I Contractor Address By Date1_2� <br /> Estimated Starling Date 17'795 Completion Date t s - J5 Permit Expiration Date <br /> I (or We) hereby apply for an encroachment permit to carry out the following work : <br /> The above named applicant hereby requests permission to- PERMIT FEE. ............. .... .. <br /> Additional Footage Fee ... .. .. ... . <br /> Sewer Tap Deposit .. ........ ..... _ --- <br /> S '� TOTAL DEPOSIT...... l�— <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> No -C'�os el 1 Ai,,A s Sha11 <br /> Bee Sti ockzd AZT A1,1� 7-t rn.-e <br /> Show sketch above or reler 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 <br /> the City harmless against any and all losses,costs,or damages resultinq 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 <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 2 RS 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 signing — Note requirement of notifications and inspections. <br /> Signed: <br /> �i _ - --- - Phone <br /> __ _ <br /> 1s1—Permillee 2nd—File 3rd—Finance 4th—tllililyI 5l reel <br />