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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> N° 61145 <br /> Applicant's Name A Date <br /> lOwner/contractor <br /> Addres B �� one <br /> APPROVED: DIRECTOR OF PUBLIC WORKS <br /> Location of Proposed Work,etc.7 1 15 M n f 5 l+s <br /> G.�t^n Giy i4� F/ �mI1n7 a 4-6 <br /> Owner/Contractor Address UJ 1J-a ,_•°•ak J six, r►a fa W. T�r 1Y� s 1 S , ,� By if, Date <br /> Estimated Starting Date �'-8�Z _--Completion Date Y-g�- .—Permit Expiration Date <br /> (or We) hereby apply for an encroachment permit to carry out the following work: _—� f a <br /> 4n kca7f 1.L fi - . <br /> The above named applicant hereby requests permission to - PERMIT FEE ... $ + a Od <br /> Additional Footage Fee. . . ... .... ... <br /> Sewer Top Deposit ................................... <br /> TOTAL DEPOSIT ...... $- /.10 <br /> Building Permit No. <br /> A�O_ improvement Plan No. <br /> Supplemental Conditions: <br /> R EC;E I V E "D" <br /> DEC A 2 1992 <br /> ENVIRONMENTAL HEALTH <br /> POMIT/50VICK6 <br /> Show sketch above or refer to drawing submitted <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 /> ReadGeneral Provisions on reverse side of this permit before signing. 'Note requirement of notifications and inspections. <br /> Permit Engineer/Inspector <br /> 944-8250 <br /> 944.8366 Signed: �!"� Ph..e;/ <br /> ist--permittee 2nd--f He 3rd—Finonce 4th--UtiIity/Street <br /> Zz- 09 <br />