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OCT-23-1997 16:57 P_BL I C 1 10PIl" PEPr11 T _EriTP 209 937 8901 P.04 <br /> CITY OF STOCKTON <br /> -� 64565 <br /> PUBLIC <br /> DEPARTMENT OF PUBLIC WORKS <br /> A;V t (�APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF WAY <br /> APpwCani'S Namo Gv)rpS +ati , l — owe��1.•"r // <br /> (Owner/comradi" <br /> AAdress DTD, oX a 51 , 5911IMA GT A vAPne�L_.a�_yt3 <br /> Lowson of Proposed won,,acS OUt1A f - CO-LLhIr Off- APPROVED: PUBLIC WORKS DIRECTOR <br /> i Vl1FNSP[�-iaA, p�- (bw 1CLU)2v, +P1 k0J&*_ P'" <br /> Owner/contractor Address Sgili 45 26Cy-, ,_ e � I owe - <br /> Estimated staeug Data W125, 141.7__eompiielan Date ocr g iqq ((Pv't EaPrtaPon Date M2 11 - IS —9�1 <br /> I (or We) hereby apply for an encroachment permit to carry out the following work : , T O I QViluct I n S to 1 * O <br /> --_4fti ., V^-t- 50CAth A _ <br /> w <br /> Ju ,� <br /> # srIII 011V OTA Road. Wdis will be- 1_ota/r� i� <br /> 117 ► +fie stAgwalk, r(kc loraAtil .�l�.Gve/!fYlbe demr- <br /> ,rN !n ►GelL)eld <br /> .,I axd im yke locaatm of waa-rrauod ut/IiFtef-- <br /> ►es K/RM+LUth l71 .4,WA it t _ <br /> Y"eoow named Moi unt nervm reaves% PERMIT FEE <br /> TION <br /> Additional Footage Fee <br /> sewer Tap Deport ..... _ <br /> TOTAL DEPOSIT <br /> Building Permit No. <br /> Improvement Plan No <br /> Supplemental Conditions: <br /> )ewrnp ONE L-awE OF —UVJ �. <br /> 47FGa-a f:4wt"13o"fi P.Y <br /> 9 i CO ArYN -14 F- Q2i, <br /> �P uttatlned <br /> $naw sgirn atgm a.mkr q tlnwny submngtl <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 an 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. I.I <br /> luli <br /> PERMITTEE SMALL CONTACT UNDERGROUND SERVICE ALERT(1-8002--2444)TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES- <br /> PERMITTEE SMALL CALL(209)937.3411 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 before signing — Note requirement of notifications and inspections. <br /> 707-q3 "155`( <br /> in vel,,.,5nea, <br /> TOTAL P.04 <br />