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"� � VOLiI. wVrtr�o rtKl9ll I.tIVIK <br /> • CITY OF STOCKTON 64613 <br /> UC <br /> AP DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-0F-WAY <br /> App(canl'S Nemo I ta:J Wte, - G2t�� _ O6 \ <br /> (OwnarlConpaalar) Date-10 �9Z <br /> Atltlraee <br /> Phona <br /> LaCaean of Pmpp d work.ete. APPROVED. <br /> —�S,S NI f�>G•I PUBLIC woRfcs DIRECTOR <br /> 1-VOL� <br /> Qwnerl Can(mww Addrean _ IS\M �, f/. •I <br /> Etamated Stertiny Dal, IO-tf ^�— Due—A4 <br /> --Comptatipn <br /> Perms E><pnatwn Date <br /> I (or We) hereby apply for an encroachment permit to carry out the following work <br /> TM afq.e nemea apolKam non ewr+n perme.n„ro. O£C Pe.., <br /> E <br /> PERMIT FEE <br /> Addiaanal Faauge Fea =1^ <br /> S.ti Tap Oa t l <br /> Cgs mpT— <br /> TOTAL DEPOSIT. <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Wo¢\` �U.4<L 0f. QE42hClS.D ZCJ <br /> 6:Q7 e.m 3'.30 A'n l'nOwsOv-f - �f <br /> OV-ee-p OF TQraV:Y,L OO Fjnj <br /> Wena ACT sill 'ryT� . <br /> L, -� c Du-w-r- <br /> Sroe anwcn wa+e or rvb.ro arw <br /> ^g:wmnlee 1156 of w. ` <br /> IMPORTANT:A Applicant y <br /> pp cant hereb agrees rees to comply with all provisions of this permit as well as all <br /> applicable <br /> standards and specifications currently in effect, and to pay to City its actual cost for removal and properr replace ordinance <br /> a 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 arty 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 shail be submitted to the <br /> City Risk Manager prior to beginning constructlor. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-800-PN(2-2444)TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL(209)937-8477 24 HOURS PRIOR To START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. <br /> Reed General Provisions an reverse side of this permit before signing — Note requirement of notifications and inspections. <br /> m-tMrninae 2ne_elle .. . __ <br /> IN-Cn.en[! �m-Ungyl S.M <br /> TOTAL P.02 <br />