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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS 615 4 4 b <br /> #SWA 01 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> A;! <br /> Applicant's Name ��XOL)ti,C Zec� >r,� s(- Date �- Z-01Q <br /> (Owner/Contractor) c± <br /> Address �� �� ��ti S+ree<4- Phone <br /> c (� ,� /� APPROVED: PUBLIC WORKS DIRECTOR <br /> � <br /> City T S�r�Y n State yr/s Zip !1 53 <br /> 26 <br /> Location of Proposed Work,etc. E0,54 'L 1 �i7fiYNrHGL /ifalP <br /> Owne Contractor Address �(.�GT�UrY1 Z36 &11/ kfym /S2!/S By Date ✓" <br /> Kk�7 'I — I <br /> Estimating Starting Date �'�J'�1 Completion Date ,0.�—� Permit Expiration Date <br /> I (or We) hereby apply for an enroachment permit to carry out the following work: Ze <br /> / — <br /> The above named applicant hereby requests permission to- <br /> / PERMIT FEE ........... .........$ <br /> T4C6-12 SemS'14,e \ Additional Footage Fee...........................$ <br /> TlN� 1 ��) Sewer Tap Deposit................................. <br /> TOTAL DEPOSIT .............$ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> DECEIVED <br /> `1AY 31 2000 <br /> ----------- <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, 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 indemnity and hold the <br /> 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 City <br /> Risk Manager prior to beginning construction. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800-642-2444) TWO WORKING DAYS BEFORE 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 rmit b re signing - Note requirement of notificattiion�s% and inspections. <br /> Signed: Phone <br /> t st-Perm ittee 2nd-File /Ird-Finance 4th-1-11,1ity/Street <br />