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11"43 —PUBLIC WORKS PERMIT CENIK Gen mor opo• <br /> •,� ®i • CITY OF STOCKTON 65217 <br /> DEPARTMENT OF PUBLIC WORKS <br /> {r APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> AaPllcanl's _ ,t;re+ra,.3�+1 ��.a1ia..T"rDate..�.f2LL9R <br /> (Owner l�"Ontr(,CI ) <br /> Address_ .`_t �;.��- S,.]Je- �^.-. .— Phone (YIL)3s2-5lol' <br /> tit.>,+aA, cA. y444 APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of P,00ased Work, etc. <br /> Owner/Coetrador Address �', ,q _ 8Dale nvapL <br /> .9� <br /> Estimated$tarting Date t I g—. Complerlon Dale �LPermit Expiration Date �yy <br /> I or We) heroby apply for an encroachment permit to carry out the following work : Iw» host��C1— <br /> Mc�l`1��f2_v.y-, r ��'�l.,� b '�- , �O4�lt•��1 pe — �A�aT, <br /> I P_ <br /> lit <br /> �J c11.5 tt1LJ \4 P. , -lRyl 1 q C� . M4�1 t•q � . <br /> The awm namea apo0nnt hemby rnquea;parmisskn to PERMIT FP_E .......... s_. L <br /> Additional Poolage Fee.. <br /> �L r r��,,� <br /> ``\.> � -r'�Xa\r T Sewer Tap Deposit ........ . ... <br /> ( - \jJ[ WC, f TIIrAI DEPOSIT <br /> lNb 1� Building Permit No. <br /> Improvement Plan No. <br /> C•��}L l}1�5T Q Supplemental Conditions: <br /> 'T� <br /> L <br /> 0.11.`( • � �� [(�),lSUG� �� �O <br /> shw.c4nlch aty..e a rear la Nawlna eaomtltea t0`c Prl a' D P4-L ��-\- <br /> _�1uA� L� tzr c�r�n LAY G,:cry lvMn . <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 t0 comply will be cause for revocation of permit. Applicant agrees t0 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 shalt be submitted to the <br /> City Risk Manager prior to beginning construction. (ca?— <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-800-'84;2-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UT1LIITIES. <br /> PERMITTEE SHALL CALL(209)937.8411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. <br /> Read General Provisions on reverse side of this permit before signing — Note requirement of notifications and inspections. <br /> ra -Cvmllee 2nrr..Rlc Y_ 9rn—FlMrve µh—UlililYl$I 1 <br /> TOTAL P.02 <br />