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1 I <br /> Pugh,IL t;-Jr t 7 ^CPT. <br /> RECEIVED ,•��� 1995CITY OF STOCKTON <br /> PFA'+41"TAPPI�RATION FORPARTMENT ENCROAC MENT ON PUBLICOF PUBLIC RIGKT-OF-WAY <br /> __ II :-3 <br /> Q N 0- 61415 <br /> F 14._1K �cd0 3 <br /> ' Apptraant s NaGrnva O H W� f �ta 7, <br /> iOwn.r/Cont O f Lr STr ! Phone v 7 <br /> �fe' APPROVED DIRECTOR OF PUBLIC WORKS <br /> Location of Proposed Work,et ys E W <br /> Aft <br /> Owner/Contractor Address By Date_rL <br /> Estimated starting Dote ,g 7 Completion Dote r `" Permit Expiration Do,.--4 �ID <br /> I (or We) hereby apply for an encroachment permit to out the following work.Dry �I qty /rls�cs �. <br /> YOl4as I �✓`- <br /> r <br /> The above named applicant hereby requests permission to PERMIT FEE S 00 <br /> Additional Footage Fee <br /> Sewer Tap Deposit <br /> TOTAL DEPOSIT S <br /> ' Building Permit No <br /> improvement Plan No <br /> ' Supplemental Conditions <br /> 1' <br /> Show sketch above or refer to drawing svbm,ned <br /> k <br /> ' <br /> IMPORTANT P Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, <br /> ti iM O PP <br /> resolutions, standards and specifications currently in effect, and to pay to City its actual cast 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 /> ermit Certificate of insurance will be presented by applicont upon request <br /> ead General Provisions on reverse side of this permtl before signing *Note requirement of notifications and inspections <br /> Permit Engineer/Inspector <br /> 944-8250Z711- ' �y7�G <br /> 9448366 S. ed Phone _ <br /> l <br /> 4 <br /> title* 2nd--*.Ie aro—Finance 4tr—Utii+ty/street <br />