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0W --� 64569 <br /> CITY OF STOCKTON <br /> © <br /> DEPARTMENT OF PUBLIC WORKS <br /> ���]� n <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGD �tHT-OF-WAY �I <br /> n <br /> Applicant's Name Z V/ h __ Date /0 JAN 2 6 1998 <br /> �r / <br /> (Owner/Contract ) 707_9� <br /> Address An Boy 2!. Iz r»� /-,A Phone ENVIRONMENTAL HEALTH <br /> Location of Proposed Work, etc. 0 VP uP APPROVED: PUBLICR6l WS, <br /> kl4i r Oy <br /> Owner/Contractor Vddress _ By Date 1 � <br /> Estimated Starting Date I I Completion Date Permit Expiration Date <br /> 2 2 g �ffml-ece <br /> I (orWe hereby applyfor an encroachment permit to carry out hlowing work : 7� �r o Y9a <br /> 61 V <br /> The above named applicant hereby requests permission to- PERMIT FEE ... $ 1 Za �C• <br /> Additional Footage Fee <br /> Sewer Tap Deposit . .. .. . Q <br /> TOTAL DEPOSIT 5_ �ZS o <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> YY r-%p -T12CVEL <br /> BE e x-oC*.�s� Y <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 <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 to the <br /> City Risk Manager prior to beginning construction. 00-1 <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800 -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 efore si g No requirement of notifications and inspections. <br /> ��` -7d7- <br /> Signedt —1164 -7 <br /> _ —__ . _ Phone <br /> 1st—Permittee 2nd—File 3rd—Finance 4th—Utihly/Street <br />