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J � <br /> J P <br /> � w <br /> V7 CITY OF STOCKTON 63489 <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT OF-WAY <br /> ApphcxnI s Name <br /> (Owner/(pntracter Date <br /> Address C a �� <br /> .0-C �_ �,A Phone <br /> Location of Proposild work etc rte_ APPROVED PUBLIC WORKS latAELTDR <br /> Owner I Contractor Address <br /> Date <br /> Estimated Starting Date .3 � � f� <br /> Completion Date Permit Exptration Date <br /> I (or We) hereby apply for an encroachment permit to carry out the following work <br /> CJ Y� t o cel,is <br /> The above named applicant hereby requests permission to <br /> PERMIT FEE7F1 <br /> Additional Footage <br /> Sewer Tap Deposi <br /> TOTAL g <br /> Building Permit No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> Xo <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 /> occunng 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)937-84111124 OURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> dINSPECTION <br /> ead General Provisions on reverse side of this permit before signingNote requirement <br /> — of notifications and inspections <br /> J I <br /> Signed ,/ �r p <br /> Phone /�� a.�C — p 30V <br /> 7st—Permittee 2nd—Erle <br /> Srd—Rnan_e 4th—U[ddq!Street <br />