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r <br /> CITY OF STOCKTON <br /> 63503 <br /> PUBLIC <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name Date �¢� <br /> (Owner/Contractor) <br /> Address 30 P n %-2crY lw 4J tllQphone L�Ib�w31� <br /> P'P+AGNO wee} CA, '�C' APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed Work, etc. <br /> 437 C A1NFD A"J— (d --NV I Fc--1 J%k <br /> Owner/Contractor Address a Bye j.�f"/�__ Date 4= <br /> Estimated Starting Date J"kk`t '15 ` 57 Completion Dale C 19, M5/ Permit Expiration Dale 10 1 1 19 <br /> I (or We) hereby apply for an encroachment permit to carry out the following work i �:"S-a"J (:,R-XL�N� <br /> tMP1N\'TC-ki <br /> J <br /> The above named applicant hereby requests permission to �— <br /> PERMIT FEE..................... $ <br /> Additional Footage Fee...... ....... <br /> SES f `�C <br /> if ED Sewer Tap Deposit ................ <br /> TOTAL DEPOSIT......... 5 `Z '— <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> ENVPERMIT/SERVICESLTH <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, resolutions, <br /> standards and specifications currently in effect, and to pay to City its actual cost for removal and proper replacement of any item which <br /> does not meet above requirements. Failure to comply will be cause for revocation of permit. Applicant agrees to indemnify and hold <br /> the City harmless against any and all losses, costs,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 work to be performed under this permit. A certificate of insurance shall be submitted to the <br /> City Risk Manager prior to beginning construction. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-800-842.2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL(209)937-841124 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. <br /> Read General Provisions on reverse side of this per before signing —�Note <br /> �requirement of notifications and inspections. <br /> Signetl _ _',/�/{T�//7(,,/Q.(L�(j_/` `�t'�_✓`"_ _ PnonA6. <br /> 1st—Permittee 2nd—File 3rd—Freance 41h— <br /> Utility/Street <br />