SITE INFORMATION AND CORRESPONDENCE FILE 1

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x CITY OF STOCKTON DEPARTMENT OF PUBLIC WORKS APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY N ° 61742 Applicant's Name ARM Prrrtlrt Gq P, 11r Dora lt}1)5-97 - (awner/Contractor) Address P-0- Pf77c `0 1 t qqn &L2 9W2 Phone415-571-2469 APPROVED: DIRECTOR OF PUBLIC WORKS Location of Proposed Work, etc 7906 El Do ado, Stockton Owner/Contractor Address By Date Estimated Starting Dote Completion Dote Permit Expiration Date I for Wel hereby apply for an encroachment permit to carry out the following work: Tnstall tin VnjrLntEr rmni_tg= 4211 as = T2VOC2ble T) =t The above named applicant hereby requests permission to - PERMIT FEE .. _ . _ . _ . . .... _... . .. . S Additional Footage Fee. . . .. . . . . . . . . . . Sewer Top Deposit ..__....... .... ----_ ---._....... TOTAL DEPOSIT ,-.,..."............... E 120 ) 0 SEE ATTACHED Building Permit No, PLATE 1 Improvement Plan No. Supplemental Conditions: Show sketch above or refer to drawing submitted IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, resolutions, standards and specifications currently in effect, and to pay to City its actual cost for removal and proper replace- ment of any item which does not meet above requirements. Failure to comply will be cause for revocation of permit- Appli- cant agrees to indemnify and hold the City harmless against any and all losses, costs, or damages resulting from injury to persons, death of person or damage to property occurring at the site of or as a result of work to be performed under this permit. Certificate of insurance will be presented by applicant upon request. Read General Provisions on reverse side of this permit before signing. * Note requirement of notifications and Inspections. Permlt Engineer/ Inspector 944-8250 944.8366 Signed: Phone