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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> N° 62625 <br /> 9P.C.,s Name C/GP — ��� '"fiJate <br /> Owner/c odor) `' _ <br /> 4ddres oc ���/ S Phone <br /> Location of Proposed work etc : APPROVED DIRECTOR OF PUBLIC WORKS <br /> U1 u r, 4` -ASSd` - <br /> owner/contractor Address 2Z12G /AyyrC. Q15--6, .)y SA_ C7-z- By Date <br /> Estimated Starting Date 4�t r ` `T ¢ Completion Date 'z /.F 3L- Permit Expiration Date—5 <br /> 1.5 <br /> 1 (or We) hereby apply for n encroachment permit to carry out the fo owl work Place- 4 5-0.1 <br /> eN e k f— �c-�* ti r�., tiG,�r�-► 1l <br /> The above named applicant hereby requests permission to PERMIT FEE S •� Q <br /> Add,t,onol Footage Fee QLOW /�Wvll V!5 <br /> Sewer Tap Deposit / r ! <br /> TOTAL DEPOSIT $ <br /> • Building Permit No <br /> Improvement Plan No <br /> Supplemental Conditions <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 Apph <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 /> Read General Provisions on reverse side of this permit before signing ' e eqof notifications and inspections <br /> Permit Engineer/Inspector <br /> �3-1844.8250 Notuirement Phonc���{g� <br /> *4tiz$386— Signed <br /> WCO V/ Fok2 (VY-flLO <br /> L !/ <br /> rt—�erm,ftte 2rb6—�,Ie ltd—Findnce Airh_Uhhty/stylet �t `��� <br />