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MHf-04--1997 15 20 FUBL I C WORKS PERMIT CENTR 209 937 8901 P 02 <br /> n - <br /> CITY OF b-TOCKTON 63757 <br /> L?EPAWrMENT OF PUBLIC WORKS <br /> A9# APPLIGA TIOPA MR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> AppBCant s Name VA YV nate,Ii i a cwD C14 <br /> (Owsrerl�Cori Cforl j� yy <br /> 0A <br /> P�dress TdL? --X I fl C�'I_ Phone fr�-1 204._ f> <br /> Local.on al Propo'sed'W.,, et IT) ! t.lX_tff�� ----- APPROVED. PLID C WORKS DIRE <br /> C LA, ,S mss}--& pi'&c, �� • _ _) _ <br /> OwnerlConlractar Addraass _ L1ate <br />' Estimated slertaig Date Camplelion Dale C �Krm3l Expiration Date <br /> I (or WQ) hereby apply for an encroachment permit to carry out the following work VVAA&,p-iilctk <br />' rna nnc„v n4MKd a*Qi,02M 10 - �p <br /> F'ERMI7 FEE 5 _ <br /> Addiifonal Footage Fee <br /> Server zap Deposil <br /> TOMI, MPOSIT 3 -- <br /> �,-c �t building Permit Na — <br /> Improvement Plan No <br /> Supplemental Condmovs - <br /> I <br /> Shaw;kpl�h aCnVe or reietU dra,.cnp EUQmN4td <br /> IMPORTANT Appfrcant hereby agrees 10 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 or permit Apphcant agrees to indemnify and hold <br /> the City harmless against any and all losses,costs,of damages Tasulting 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 submilted to the <br /> City Risk Manager prior to beginning construction <br /> I PERMITTED SHALL CONTACT UNDERGROUND SERVICE ALERT(1-804$42-24144) TWO WORKING DAYS BEFORE BEGINNING <br /> WoHK rOn Ld7f;,A ioN OF UNDERGROUND UTILITIES <br /> PERMITTEE SHALL CALL(209)837-8.411 24 HOURS PRIOR TO START OF WORK FOR A CONTROL_NUMBER AND TO SCHEDrJLiE <br /> INSPECTION 1 <br /> Read General Provisions an reverse side of thispe before signing — Note requirement of notifications and inspections <br /> it <br /> ted—pprmirlpn 2nd -Qr - 9nf—Fknwn[g 4m-1.111Irtyl SIMt4 <br />