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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS i <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-:OF-WAY <br /> Na 61637 <br /> Applicant's No AY(- X,5 QC I `� I•�" <br /> —� O� <br /> /con r .8 Phone 201 <br /> �C?eS CA q53 5 t `+ APPROVED: DIRECTOR OF PUBLIC WORKS <br /> Location of Proposed Work,etc. !�4 C�� S q v+�. 5�•s <br /> s�� 'cs�• 4�J1aor �� �aNr i�as ��f 5�. <br /> f •� 4 <br /> Owner/Contractor <br /> BY Date <br /> Estimated Starting Date��(� Completion Date' Permit Expiration Dote <br /> I for We) hereby apply for an encroachment permit to carry out the following, work. <br /> clf. a 1-t r '1 0Yr" 3 CVt +4,L ca�.ak 50,J s 1 $ slw lol"rf <br /> +'1 waL C14wA-+ W�\ <br /> The above named-applicant hereby requests permission to • PERMIT FEF <br /> I <br /> 324 <br /> '- 4 <br /> --.ATC.AOC <br /> SSIA7ES INC. . <br /> �^ -579-2221---:' <br /> _ <br /> - Date �a <br /> - :_1117.LONE PALM AVE..SUITE B ••.... i <br /> - -MODESTO,CA <br /> 95351-1502'-.-.. <br /> ., - - $ I Z •OO <br /> _pay to the r C�-� <br /> orderof 1 .. © 80 00 Dollars <br /> 3S: ... <br /> �CCCWE5 MERICA BMNK <br /> KApSAS OMICE 1400.848-10M - _ NP . . <br /> 1500 KAL SAS AVE. <br /> WDE90,fA95358 <br /> do <br /> I` <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 /> Read General Provisions on reverse side of this permit before signing. •Note requirement of notifications and inspections. <br /> Permit Engineer/Inspector n " <br /> 9448250 �Jlw+ni QM` <br /> 944.8988 Signed: —Phone. <br /> 1st---Permittee 2nb-file 3rd—Finance 4th--Utility/Street <br /> ' F <br />