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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant s NcmdA'r-iT/C �JJ✓/IOO/!l�/l/O/CT/D!/6 Date �6 5 7 6 6 2(Owno /contractor) <br /> Address Phone <br /> APP OV D; DIRECTOR OF PUBLIC WORKS <br /> Location of Proposed Work,etc. <br /> Z/off �� v Z�Z'z <br /> i /7 O <br /> Owner/Contractor Address -���`'r' ^/ By Date <br /> Estimated Stoning Dote Completion Dat —Permit Expiration Dore <br /> I (or Wel hereby ap 1), for an encroachment permit to carry out the following work: <br /> .. s e. <br /> The above nomed applicant hereby requests permission to - PERMIT FEE __..._.. . _. ._.. ._ S GOV <br /> Additional Footage Fee <br /> Sewer Top Deposit <br /> See exlended 51* aw#' <br /> Q TOTAL DEPOSIT .......... $ 00 <br /> Cathzch d <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplementa/l/Conditions: <br /> u/ Yy� /✓�n�o�.Te LO.rCI <br /> S/uric/ oft /4/ /r G . / <br /> �rlG/JG /C'o7�/o t/ te�i �sv6e !`O <br /> of S�,e�o,v <br /> Show sketch above or refer to drawing wbmined <br /> IMPORTANT: Applicant heref,y agrees to comply ovist s of this permit at well as all applicable City ordinances, <br /> resolutions, standards and specifications Curr eJnts nal to pay to City its actual cost for removal and proper replace- <br /> ment of any item which does not meet abo re u . Failure to comply will be cause for revocation of permit. Appli- <br /> cant agrees to indemnify and hold the City h s 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 R <br /> 944-8492 <br /> 944.8366 Signed: mQ Phone 7V0 "� �K` <br /> IFt—Permittee 2nd dF 3rd—Finance 4t1h—Uti Lty/Stroe t <br />