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CITY OF STOCKTON <br /> DEPARTMENT OF- PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> � 57614 <br /> Applicant s Name �6'G �� ��t �e v 2 �'�7 <br /> (Owner/e 0, <br /> roct <br /> AddressI yt 1i-' k. Phone�!(G'�s(_G� }f <br /> t 7 -� �, APPROVED DIRECTOR OF PUBLIC WORKS <br /> location of Proposed Work etc � � �L�L� �� <br /> owner/Contro0or AddressBy <br /> Estimated Starting DoteJ-7-1*1-1,11� Completion Dote 9 Permit Expiration Date <br /> 1 <br /> I (or We) hereby apply for an encroachment permit to carry out the following work t r <br /> The above named applicant hereby requests permission to PERMIT FEE S <br /> G3 6 ��� Additional Footoge Fee <br /> Sewer Top Deposit <br /> TOTAL DEPOSIT S D J <br /> Building Permit No <br /> Improvement Plan No <br /> Supplemental Conditions /'2i2 �EJVGf�BGU <br /> Show sketch above or refer to drawing subm tied <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 to 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 o 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 requirem t of notifications and inspections <br /> Permit Engineer/Inspector <br /> 944.8492 , <br /> -A <br /> 9448366 Signed Phone <br /> tsl—Permittee 2nd-4ile 3rd—Finance eth—Util Pty/street <br />