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64203 <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name �r �dJUIrON/�1-�+�±LDate - <br /> (Owner 1 Contra <br /> Address r/`�/r 6 �r'r L v # Phon�`1�!✓J✓9 2 rT <br /> APPROVED: PUBLIC WOR($D{RECTOR <br /> Location of Prosed Pork,etc. • - <br /> C --- — <br /> L <br /> Owne C ntractor Ad ress .-5�4 0� -j--- q— By _Date 50" 0� <br /> 33 9T ^3` / 7 Permit Ex iration Date Z ' �5- - D-7- <br /> 1 - <br /> Estimated Starling Date Completion Date f /p <br /> 1 (or We) hereby apply for4n encroachment permit to c rry out the followin work : A <br /> o4-u el CPO <br /> �- - be (71%cp <br /> e Ir- t '► ie b e 4e lei u4O AJ Th- t /v�'/' <br /> , A eo <br /> Ems,-►Y.k <br /> The above named applicant hereby requests permission to PERMIT FEE........ ............. <br /> Additional Footage Fee............. <br /> Sewer Tap Deposit <br /> TOTAL DEPOSIT. . ...... $� <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> ypsayiQ <br /> JAN 311997 <br /> ENVI�RM�ER tCESffN <br /> Show sketch above or rerer to drawing submitted , <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(1-8002444) TWO WORKING HAYS SI�FORE 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 per W <br /> o a sig Ing -- Note requirement of notificatio-/n/�ss and inspectioonns. <br /> Signed: _ Phon (RO. `� L,o <br /> � J <br /> 151—Permitlee 2nd—File 3rd—Finance 4th—Ulility f Skeet <br />