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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS b <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY MARO 5 200, <br /> O � <br /> 0 1 ODZS701 <br /> A9# �r�t1PY r, CSY`CQ E BVI,;QNMEN T HEALTH �` <br /> AppIicaM's Narr�l.� n Date <br /> (bw=Zosntractor) + ERMI T/SERVICES <br /> Address Phon <br /> �] �-�1� APPROVED: PUBLIC WORKS DIRECTOR <br /> City State _ Zip "1 l <br /> Location of Proposed Work,etc. <br /> Date _ _ T— <br /> Owner/Contractor Address p�-� <br /> Estimating Starting Date VA 2112 �V Ll ` Completion Date Permit Expiration Date <br /> I(or We)hereb apply for an enroachment permit to carry out the following work: <br /> , . <br /> in �V ' <br /> L4 fn li�, <br /> The above named applicant hereby requests permission to- I PERMIT FEE. $ <br /> ........................................ <br /> 12 5i'6 <br /> Additional Footage Fee...........................$ <br /> Sewer Tap Deposit................................. <br /> TOTAL DEPOSIT.............$ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> OO No lane. LI0s0(e5 art✓ JN,fM'ttte—a- <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 e`fect, 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 indemnity and hold the <br /> 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 City <br /> Risk Manager prior to beginning construction. <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800-642-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <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 /> r <br /> Sign. <br /> Phon <br /> 1st-Permittee 2nd- ' 3rd-Finance 41h-Utility/Street <br />