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CITY OF STOCKTON <br /> 'J DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF=WAY <br /> N ! 62646 <br /> Applicant's Nomald^SjYIN Gr. r , o_� Date <br /> /Connacrorl { <br /> ;idres I -1 Z.Z � • rJ i'LrTS 6.V C. Phan_ <br /> Location of Proposed Work, etc.bAW - 10AQ IN CDr 6AfLAbj5 APPROVED: DIRECTOR OF PUBLIC WORKS <br /> --, I 30 - HVNTa 6TZ>z f4p" i CA <br /> /Contractor Address ��A�I ,rLEWMIJA 11J 9y <br /> Estimated Starting Date SY t3 /9 T Completion Dote a / 13� � � Permit Expiration Date <br /> (or Wel hereby apply for an encroachment permit to carry out the following work: ' , + PS+ti+gt/' <br /> i n <br /> OT- fT/f. <br /> The above named applicant hereby requests permission to - PERMIT FEE ...__ . ..... . . _ . $ <br /> 7:me1 W&VZ'J4 — �O rc� Additionol Fowaae Fee. <br /> wo 2 <br /> "D6ry'l.-i - Sewer Top Deposit ....-......_...._._ ............ .. <br /> � <br /> Go ,�, t'� L.L, rcN r�cA IS TOTAL DEPOSIT .....- $ �zo <br /> Building Permit No, <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Klfx ', 4 &;0 - Zo <br /> Show sketch above or refer to drawing submitted <br /> LL <br /> IOZ�► <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 ED ALF( <br /> 937444-8260WfIKLEVE Phone Z" 9+`3 i31� <br /> 7 844 8386 Signed: <br /> cj -LL 83'7 - 9461 Fol COVUL, HO0VA6 ' n, 148 - 1+91730- I 1Ra1' <br /> , , _( speur, ) Vt�Vl,I_Or z. K9c�r�s moo . <br /> io OF 1404. <br /> l-st- permittee 2nd—File 7rd_Finance 4th—Utility/Street <br /> I <br /> I <br />