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11 for 1y�r l� �� �lt-d ��-dkJ_U Iia f1Ul llitKlV t�rL1F rf �E: J. <br /> 64547 <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUSUC RIGHT-OF-WAY <br /> Apps cants Name Date— -- <br /> {Owners roe r)_ M i�w r+.�►�+o + 6ne n• <br /> Aadreae <br /> aaysOUEo: pus>LIc woplc13 DIRECTOR <br /> Lnagtten Of Prppaasd Work sto z !— <br /> Owner/CWlr&Mt AdCrow By Date <br /> estimated Starting Dale cornpietion Date 92'" Permn Expiration pate t <br /> o L <br /> I (or We) hereby apply for an encroachment permit to carry out the following work <br /> C3 �'� ✓ la.�,� <br /> The abava namea applicant Mrovy requests pwrnissron to PERMIT FEE $ <br /> Addilronal Footage Fee <br /> Sewer Tap Daposlt <br /> TOTAL DEPOSIT S <br /> Building Permit No <br /> Improvement Plan No , <br /> Supplemental Conditions <br /> A-o~ zwk'— P¢.G*CsS <br /> -Vz; ) v0ai C%va <br /> Tai� Com+►L,'''� . <br /> 4^e- AM-A-4 "-r TqJ <br /> $how gkatch above or refer to draymtg submitted ei 1.r� <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 actusl 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 snsurance shall be submitted to the <br /> City disk Manager prior to beginning construction <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-800 2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDSROFIOUND UTILITIES <br /> ISERMITTEE SHALL CALL(209)937-8411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL N�+I-ND TO SCHEDULE <br /> SPECT1ON f j `7,C� J CLO—L' i <br /> Read General Provisions an reverse side of this perm) efor+e grting — Note requirement of notifications andtInspection% <br /> - <br /> 3-SD10 <br /> IV-Permittee 2nd—Pi1e ,lyd—F arca dth-�lil��ilf!Stre6t <br /> C! <br />