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-r,CAW <br /> CITY OF STOCKTON 6 3 5 0 3 <br /> SA <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT OF-WAY <br /> Applicant s Name - <br /> (Owner/Contractor) Date <br /> �""'-`-- <br /> AddressC ,c .1C ttpPhone <br /> CA, vii 7� APPROVED PUBLIC WORKS DIRECTOR of Proposed work etc <br /> - u_c+`Qtit�� <br /> owner/Contraclor Address <br /> 1 <br /> Completion Date <br /> Starling pate Date <br /> � <br /> A uca . 1 1 45 permit Expiration Date 1 �s <br /> I (or We) hereby apply for an encroachment permit to carry out the following work <br /> — L� <br /> The above named applicant hereby requests permission to <br /> PERMIT FEE $ \� - <br /> Additional Footage Fee <br /> fE�-D Sewer Tap Deposit <br /> Y I/v C7 TOTAL DEPOSIT g_ z <br /> Building Permit No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> J1? 1 4 1995 <br /> NVIRONMENTAL HEALTH <br /> PERMITISERVICFS <br /> [--S,.. <br /> 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 (1-1300-1342_2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES <br /> AWkRMITTEE SHALL CALL(209)937-13411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> ECTION <br /> Read General Provisions on reverse side of this per7t before signing — Note requirement of notifications and inspections <br /> Signed Phone�j16 .6)7�r1-1,374040 <br /> — — — — - ---- <br /> is[—Permittee 2nd—File <br /> did—Finance 4th—Utility/Street <br />