Laserfiche WebLink
CITY OF STOCKTON NOV 0 91992 <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY ENVIRONMENTAL HEALTH t <br /> PF�;t�QITlSF,l2�T 2 <br /> Applicants No <br /> �I vv __ oD 11 44 <br /> d r `°" �'r!4 49_. r9 e thane z <br /> S APPROVED: DIRECTOR OF PUBLIC WORKS <br /> Location of Proposed Work, etc. <br /> �D11/1�flJ�L� it x /)& 40 fj <br /> owner/Conttoctar Address_6 6By � onto <br /> Estimated Starting Oate //`�D�Completion Date` 7 Permit txpirotion Date— <br /> I (or We) hereby apply for an encroachment permit to carry out the following work:41l! <br /> noThe above named applicant hereby requests permission to - PERMIT FEE ... ... . . . . .. . . . . .. . . .. . . . .. . .. . .. . . . . . . . . .. . <br /> Additional Footage Fee. . . .. .. . . . . . . . . . . . . <br /> Sewer Tap Deposit . . . . . .. . . .. .. . . ...... . . . . . .... ... . . . <br /> TOTAL DEPOSIT ... . . ...... .. ...... .. . .. s <br /> Building Permit No. <br /> Improvement Plan No , <br /> Supplemental Conditions : <br /> W&ZG C51 wl.G 96 A <br /> /Y1/,Pi�rtu Pry /O t 0�1 Nl <br /> Show sketch above or refer to drawing submitted <br /> i <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 /> Reed General Provisions on reverse side of this permit before signing. * Note requirement of notifications and Inspections. <br /> Permit Englnserllnspeclor <br /> 44=8250a <br /> 94448388366 sign d: (�,'l(�sr�-w— � Phane9/6 85z- 6 2fo <br /> oFlyI.t--0ermittee 2nd—file 3rd—Finance 4th—Utility/Street C a <br />