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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> N° 61066 <br /> Applicant's Name���-s <br /> IOwner/Centra��/'i n fi7i � O_ P�ne��esq)oZ� l 915 <br /> Addr.s.G APPROVED: DIRECTOR OF PUBLIC WORKS <br /> Location of Proposed work,etc.—F3. Q'i�C- /A �4Ci <br /> By <br /> owner/Cont cwtor Address Gq� <br /> .completion Date q-30—`ja- Permit Expiration Date <br /> Estimated Starting Date <br /> S <br /> I (or Wel hereby apply for an encroachment permit to carry out the following work: — <br /> G <br /> er oi, c.c S �r <br /> The above named applicant hereby requests permission to PERMIT FEE ..___..............__......... S <br /> Additional Footage Fee. . . .. .__.. ... <br /> Sewer Tap Deposit ._._._._.__....___.__.... <br /> TOTAL DEPOSIT S <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Show sketch above or refer to drawing submitted l/ V <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 re uestrequlrbmenlofnotlticatlonsendinepecliona. <br /> Read General Provisions on reverse side of this permit before sig <br /> Permit En flnspector �� Q 1 25 Cl <br /> 944-8244-82 50 Phone b / <br /> 944.8388 Signed: <br /> 1st—permittee 2nd--file 3rd—Finance 4th—Utility/Street r <br />