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ffas' \W-111 CITY OF STOCKTON 6 4 5 4 7 <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name 'v `�`' 10�h��� Date <br /> (Owner/ tractor) <br /> Address 11'ISO M011"Ier Qavk I��uC �i4r.ctw�ov�Wj9}(one `- CO <br /> Z3IS N• FI PDVIC, to S� k,E APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed Work, etc. t7C ov` <br /> Owner/Contractor Address By D Date q ' Zg " 9-1 <br /> Estimated Starting Date O--Z9 � Completion Date q=-3110—9 Permit Expiration Date 9:7 <br /> //�� fl <br /> I (or We) hereby apply for an encroachment permit to carry out the following work : P�S4 1/Z <br /> Pre,vGt <br /> S�'F-tLL C tt� SZEX�CTGt�I S�lVmL2S�S <br /> The above named applicant hereby requests permission to• <br /> PERMIT FEE..................... $ <br /> SAdditional Footage Fee............. <br /> Sewer Tap Deposit ................ <br /> TOTAL DEPOSIT......... $ Z O <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Po¢.K"'A b Ljc�= erg vC�uYS►]G <br /> +dT Ltr���+C "'t1.t'n�` t�AQ��1Co �►'-Tc Go.i.t2 s�Tr <br /> Show sketch above or refer to drawing submitted "'T'i5 Wi�Q,1L <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. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (11-80044,t-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 permi efor/e�signing — Note requirement of notifications and inspections. <br /> ,���(( t O ZZ oo <br /> Signed "�`/G� _ Phone 'rE�J•-oG�f� <br /> , <br /> st—Permntee 2nd—File 3rd—Fnnce 4th—Ulilny/Street <br />