Laserfiche WebLink
CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS "� '` <br /> I 11 APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name C` U:.fLJL,.Y2 / l: ,-Cup <lat . Date <br /> (Owner/Contractor) 1 I S7C - �9 S <br /> Address SZI: 3 J ar j O y Phone .�ZwI [l Li <br /> ry Oc L?J"/16k p 9LIGO 7 APPROVED : PUBLIC WORKS DIRECTOR <br /> city ++ state rr Zi <br /> }4 lk L""t: LZ <br /> Location of Proposed Work, etc. -bn S' l � n �i� maltr7y ;,dtl <br /> J IcJ<<, lul ;01 <br /> Owner/ Contractor Address �`�R�`4-- By•- <br /> Estimating Starting Date /` LLf �1 2CCC Completion Date ZV Pxll3 Permit Expiration Date <br /> I (or We) hereby apply for an enroachment permit tqq carry out the following work: U77 54i=41l CIq ', l h C2 * MC/1163-7 <br /> 6kZeebJ +a 1 t2 lcCc. &tL n fit S ; c0wnik In '� f C� <br /> c i17E S tP enc Ave <br /> I �. S; Ct�""G� � �Jr ( � [�. CC Ckrr ( (L.� -Lz- <br /> L. ' tll L1 2 c S' (, 5it� Tc rc � a� nc� / / 2 ' ' t,;-fI bcz4t. 0. C ^ �* <br /> 7 <br /> The above named applicant hereby hiouesls permission lo - PERMIT FEE <br /> Additional Footage Fee ...... ....... 5 <br /> Sewer Tap Deposit ----- ...... <br /> TOTAL DEPOSIT ............. S <br /> Building Permit No. <br /> Improvement Plan No. <br /> n <br /> V Supplemental Conditions: <br /> Ac WCAyy <br /> � Z). F,'iI' `'` iZ <br /> Cz'�i'4 � �•\Cl CC:I�SL� � � 1\ `\1tNCS - <br /> �.� �11% �� Ll�lk <br /> Show sketch above or refer to drawing submitted eta\ - � � i-� ` `- li a�5. <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, resolution, <br /> standards and specifications currently in effect, and to pay to City its actual cost for removal and proper replacement of any item whit <br />! does not meet above requirements. Failure to comply will be cause for revocation of permit. Applicant agrees to indemnity and hold th <br /> City harmless against any and all losses, costs, or damages resulting from injury to persons, death of person or damage to proper <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 Cit <br /> Risk Manager prior to beginning construction. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (11,800-642-2444) TWO WORKING DAYS BEFORE BEGINNINt <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL (209) 937-84140HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDUL <br /> INSPECTION. wrap <br /> Read General Provisions on reverse side of this permit before signing - Note requirement of notifications and inspection. <br /> sgned � v <br /> 4;71 1t=;0 Ci �cnrwa� v Phone: S/tl � �93 — Sfbt <br /> lst-Permetea 2nd-Isle 3rd-Finance Mh-Uhliry/SbcrY <br />