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r CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> NO 62238 <br /> Applicant's Name RSR ZWDusTaL 65 Date <br /> towners TIM <br /> per t Let Cns�� eariye f 545a 2-W Phone916 - $S2 fee <br /> Addr.ss-.111�t` Leh <br /> Location of Proposed Work, etc. I b 11 Ho rNm er In if q.&C . APPROVED: DIRECTOR OF PUBLIC WORKS <br /> awry / onrroctm Address Sarney Date 1 ' <br /> Estimated Starting Date SLI�'al' pletion Dote � � �[ —9 6permit Expiration Date- !2 <br /> I (or Wei hereby apply for an encrachment permit Jo carr out the following work: &, 114.7d ( nSla /1 One <br /> �nr�h �a., raur� Jir Cii �, o Sfack�h ri �th taFrc�a� <br /> The above named applicant hereby requests permission to PERMIT FEE . . _ _ . . .. .. . . . . . . . . . . . . .. . . .. ... . . . . . . .. . . . . . . f Up 00 <br /> Additionol Footage Fee . . . . . F . . _ . . . <br /> Sewer Top Deposit . .. . . .. . . . . .. . . . . .. . . . . .. .. . . . . . . . . . <br /> TOTAL DEPOSIT ... . . ... ... .. . . . . .. .... . f Ov <br /> Building Permit No. <br /> Te 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. 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 /> Reed General Provisions on reverse side of this permit before signing. * Note requirement of notifications and Inspections, <br /> Permit Engineer/ Inspector 916 <br /> �i 9444250 / $ SZ - 6640 <br /> 944.8388 Signed: C//CG�IIt�O Phone <br /> t <br /> a <br /> Ise---Permittee 2nd—,File 3rd—Finance 4th—Utility/Street <br /> I <br />