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j <br /> �rtwo <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> ��///1 O N° 6 1 1 0 0 <br /> Aaplleant'e Norna�'� "`�L�"'��7 Dote% //n1� <br /> Iar.+r/cenr.ectarl <br /> Adder u 7 Vl 'AI t-yW rep,s,­'C'xr;e Phone. 67/-d.S <br /> (_ � <br /> ��� <br /> C ^ `�. APF7fEOVED: DIRECTOR OF PUBLIC WORKS <br /> leeatien <br /> of Proposed Work,etc. <br /> GJ'4h [3101 p <br /> 0,./Controcfor Add'eu By Dats /_.�. �L <br /> Esamoted Starting Dote _I� m Completion Dale /O f �]�- Permil Evpirotion Dat! �/���/9 <br /> I (or Wel hereby appl for an encroachment permit to carry out the following work: ��� Dnp <br /> The oboes nomad applicant hereby requests permission to PERMIT FEE _._._....._._....._____.. _. . . f <br /> Additional Footage Fee... . ... <br /> S Sewer Tap Deposit <br /> TOTAL <br /> BuildingPermit No. .. . s <br /> �O <br /> VfO <br /> Improvement Plan No. <br /> _Pt,V-A_'_T Supplemental Conditions: <br /> Show sketch above or *for 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 Engineer/Inspector p �—/ /SIO) <br /> 944-8366 - / / tG�L�t�c/L - z 1 <br /> 941-8388 Signed: rt//_.r.-. tn./ Phone <br /> Irt—fernllnee 2nd—file Jrd—Finance Mt Utihty/Street COPY <br />