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u�,i co/7 r 1 r:c.] U</{laJ 1-JMI.l LJ T iL✓�'J464G1.]tl Wl'JG <br /> 64352 <br /> CITY OF STOCKTON <br /> LEPARTMERIT OF PUBLIC WORKS <br /> APPLICA r1b 3 6 IR Er=OACNMENT ON PUBLIC RIOHT-or-WAY <br /> Cl Applicant's Name _._ 771E_.L,^.e _ _ ,Date <br /> `�..I rf Dontraclorl _ ,r <br /> Addre% _ Phone��A)a1-t'.T <br /> save*- APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed Work,eta <br /> r If <br /> _ H.s- <br /> Awae./COMraGor Address yLl_•T1111r1G�.Dete "17 97 _ <br /> J�( I <br /> Dalimeled Starting Dale __I (J __ ? .. mpatlnn OaW z/PZ._ Pormil Expiration Date <br /> I (or We) hereby apply for an encroach '•f mlt to carry out the fallovAng work <br /> l <br /> r - <br /> TAa aso.e lamed WpWaot nereq p r Ib•bn b- PERMIT FEE.. ............... <br /> Addlnmal Fodage Fee...._....... ___ <br /> P - <br /> �" Sewer Tap Depoalt .. . <br /> tt7TAL.DEPOS7T...._.., <br /> Building Permit No. <br /> • r <br /> Improvement Plan No_ <br /> EE <br /> Supplemental:Conditions: <br /> I A11 V�Q�rG SL•�1-Jr E3r:- Q.�"�� <br /> I , Zip � vl�CK flt�11_`C> <br /> f <br /> Shw"ah al or mb,b • abd <br /> IMPORTANT:Applicant hereby agrees b i ii to pl with all provisions of this permit as well as all applicable City ordinances,resolutions, <br /> standards and specifications currently cif ct,End to pay to City its actual cost for removal and proper replacement of any item which <br /> does not meet above requirements. Fal ureIto' mply will be cause for revocation of permit. Applicant agrees to Indemnify and hold <br /> the City harmless against any and all loi a cot ts,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 k to be performed under this permit. A certificate of insurance shall be submitted to the <br /> City Risk Manager prior to beginning 9 0 ucl ion. ((d�d47i <br /> PERMITTEE SHALL CONTACT UNDEI I0 up D SERVICE ALERT(1.900.6ft240.4)TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGF 0, D TILITIES. <br /> PERMITTEE SHALL CALL(209)937-6 R URS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. <br /> Read General Provisions on reverse ii4sof his permit before signing— Note requirement of notifications and inspections. <br /> tai—Pormdbe ' rd—Rb itrfSeem <br /> I <br />