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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> 60098 <br /> Applicant's Naw - -- <br /> (aarner/Contractor) - Phone�sg 3aZ <br /> Addret APPROVED: DIRECTOR OF PUBLIC WORKS <br /> Location of Proposed Work.ate. _ <br /> LAZIL <br /> B Dat <br /> Owner/Gontroctor Address <br /> l Completion Date S L —Permit Expiration Dot, <br /> Estimated Starting Date <br /> I {or Well hereby apply for an encroachment permit to carry out the following work: r <br /> lip�l o <br /> The above named applicant hereby requests permission to • PERMIT FEE................................................ $ �� S <br /> Additional Footage Fee.... ..... .............. <br /> Sewer Top Deposit .................................... <br /> TOTAL DEPOSIT ........................ $ SO <br /> Building Permit No. --- <br /> Improvement Plan No. Zl <br /> Supplemental Conditions: <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, <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 Engineerlinspector <br /> 94' -8366 Signed, I Phone- <br /> lot—permittee 2nd--file 3rd—Finance OhI IIty/Street <br />