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L <br /> CITY OF STOCKTON <br /> ' DEPARTMENT OF PUBLIC WORKS 65697 <br /> Q APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> #ant s Name 11&YI ` G <br /> Date <br /> wrirlCntroacto <br /> ` �, <br /> Address 316�1 7a i I��� �t.. t 2Y� Pnone 94-01- eD <br /> tyR ela �5'6 yo <br /> APPROVED PUBLIC WORKS DIRECTOR <br /> Ci t r a +]r �Vc. State c-Czip L <br /> Location of Proposed Work etc <br /> 1 wer Ave. <br /> Owner/Contractor Address �L� ,�4�yV�-�� B Date �y _— <br /> .�� �R 2vu t' co <br /> Estimating Starting Date pietion Date X� I Permit Expiration Date - 13 `67r, <br /> I (or We) hereby apply for <br /> a''nenroachment permit to carry out the following work 4 Ili1 CA_ <br /> elk G� G- <br /> L - Ca d 4( ` 0 < 020C <br /> The above named applicant hereby requests permission to PERMIT FEE $ r <br /> j l Additional Footage Fee $ <br /> We Sewer Tap Deposit <br /> h� TOTAL DEPOSIT $ <br /> 1 Y Building Permit No <br /> I J Improvement Plan No <br /> ./ <br /> Supplemental Conditions <br /> r�Qec�tc� <br /> vier Ave <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 e`fect, 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 the <br /> 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 City <br /> Risk Manager prior to beginning construction <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800-642-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES <br /> MMITTEE SHALL CALL (209) 937--8444HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCMF-DULE <br /> PECTION 133W <br /> Read General Provisions on reverse side :VFV( Detv,l,A <br /> ng - Note requirement of notifications Land inspections <br /> Signed r t✓�z� V, Phone _r1d3 V�� f �VV <br /> ist Permittee 2nd File 3rd Finance 41h Wility/Street <br />