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MAY-22-2000 15: 19 PUBLIC WORKS PERMIT CENTR 209 937 8901 P.01 <br /> CITY OF STOCKTON �1 <br /> DEPARTMENT OF PUBLIC WORKS U <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Ago <br /> DatO <br /> 11Name2 <br /> tRplatsntractoo <br /> /���hv Phone E29_�Jtc <br /> Address U?C/ .—Y,�- APPROVED: PUBLIC WORKS DIRECTOR <br /> city —.Statep <br /> ��- Zi <br /> LOCetlonpl Proposed Work,etc. <br /> '}� iL' �� U ►t'V' <br /> By <br /> owner/contractor Address <br /> Completion Date S^.Z`F Z,-(20 Permit Expiration Date <br /> Estimating starting Date - <br /> I (or We) hereby a ply for an enroachment permit to carry out the following work: <br /> Cp r) Y vu � sn l2L t <br /> The above named appticwnt hereby requeaa permiwan to- PERMIT'FEE ........... ------5 f <br /> r <br /> Additional Footage Fee-..........................$ <br /> Sewer Tap Deposit................................. �— <br /> .�r f ora <br /> TOTAL DEPOSIT S ` <br /> Building Permit No. <br /> improvement Plan No. <br /> Date .1 t7 Supplemental Conditions: <br /> post-IV Fax Note 7671 5 r Ly d page i NOTE " <br /> -72" <br /> 2 tt 5,�,,� <br /> To jvl Q From 11I j/1{ T+�YY]i/t i- �a <br /> trzA Ve, <br /> Co/Dopt. <br /> L.l<1V r t�P�l � Q/� I� nor, EIdv f }tLtdltP/� u UL1Yte f - <br /> pnone# Phone# q3`7~b&A0 <br /> Fax# <br /> Fax I'f-(OS� .r-- <br /> avoA dah-lc96 to <br /> �--r- <br /> Shaw sketch ab-l"or refar 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, to pay to City its actual cost for removal and proper replacement of any item which <br /> ;g:to <br /> nd hold the <br /> does not meet above requirements. Failure to comply will be cause for revocation of permit. Applicant agrees to <br /> Cit harmless against any and all losses, costs, or damages resulting from injury to persons, death,, <br /> Y # > 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 UNDERGROUNA,UTILITIES. <br /> PERMITTEE SHALL CALL(209)937��HOURS PRIOR TO START OF WORK FOR A CONTROL NUMBER AND TO SCHEDULE <br /> INSPECTION. <br /> Read General Provisions on reverse side /thiserm' be • Note requirement of notifications and inspections_Phone,gignodt5t.PermIttee <br /> mrd-Fina 41h•UtilllylStreet <br />