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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-0F-WAY <br /> N2 62298 <br /> rcont s Nome <br /> /Crxnroetar) <br /> Addm w�'>r Phon 6 ,;--LIZOP <br /> Location of Proposed Work etc--65-- F &ZnZ U' APPROVED bIRECT R OF PUBLIC WORKS <br /> s� � I•I C <br /> a'eroer/Controctor AdeV*ss B Dose <br /> Estimoted Starting D0Te��� rti4Compiet�on Dos J Perm Expiration M► U <br /> I Jor We) hereby apply for on encroachmenj permit to tory out the following w k <br /> ^ er <br /> The above named applicant hereby requests permission to PERMIT FEE <br /> Additrorso! Footage Fee <br /> Sewer Top Deposit ^� <br /> Flax, TOTAL DEPOSIT <br /> Building permit No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> Prl�`7` l/t�i.i�-r 1�►.,��L. �l�" /ti ops <br /> �rr�l` Ta 4f'11, <br /> Show sketch above or refer to drawing submined <br /> IMPORTANT Applicant hereby ogrees to comply with all provisions of this permit as well as all oppircable City ordinances, <br /> resolutions stondards and specifications currently in effect, and to pay to City its actual cost for removal and proper reploce <br /> ment of any item which does not meet above requirements Failure to comply will be cause for revocation of permit Appli- <br /> cant ogrees to indemnify and hold the City harmless against any and oil 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 <br /> 4-944-8250 <br /> 9448366 5ipned Phan 91 G -?72-y70D <br /> Ist--40errmtree 2n6`44ie are-.-F-nance 4t1'—uti1ry/Street <br />