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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> 55882 <br /> Do <br /> ssi� Z y <br /> te <br /> AvpliconYs Norm / 3 <br /> lorror/contract r) � �d/ l of o✓4(one APPROVED: DIRECTOR OF PUBLIC WORK <br /> Addrss_ <br /> Location of Proposed work,etc. I <br /> �br}/G /1✓F%= <br /> Date <br /> eY <br /> oensr/Contractar Address�c�-- yy �� Permit Expiration Date <br /> rj /6�BB <br /> Completion <br /> E t t d St h 9 Dat <br /> Cpl t Dote <br /> Ll ON pa•.t/.✓ ON <br /> k. <br /> (or Wel hereby app <br /> I ly for an encroachment permit to carry outthe following ver <br /> !J <br /> r <br /> The above named applicant hereby requests permission to - PERMIT FEE...-....._.__........__.._...._.... <br /> f G <br /> Additionol Footage Fee._ . <br /> Sewer Top Deposit .................................... <br /> TOTAL DEPOSIT ........................ f <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental//Conditions: <br /> ��� lGoi� 7'� 6G G�iiA6A %H 4LLoilI�ViG <br /> / <br /> Cc�rvoYy 3 /9BB Q's i'ssr� dy 4e 'p,-e./6' <br /> T✓/fj"/G �nY-so�.S�it/� �r�e.�...�r.O iii acco�yt� <br /> Show sketch above or refer to drawing submitted T/7C✓G1S6'o// pG `Ji �/t?.T/'� !d G�OJ✓r <br /> /i0/ T c q.0o .4./l/,CS"ovjfl: 6ov,1. ar. <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, <br /> resolutions, standards and specifications currently in effect, and to pay to City its actual cost for removal and proper replace- <br /> ment of any item which does not meet above requirements. Failure to comply will be cause for revocation of permit. Appli- <br /> cant agrees to indemnify and hold the City harmless against any and all losses, costs, or damages resulting from injury to <br /> persons, death of person or damage to property occurring at the site of or as a result of work to be performed under this <br /> permit. Certificate of insurance will be presented by applicant upon request. <br /> Read General Provisions on reverse side of this permit before signing. •Note requirement otifications and Inspections. <br /> Permit Engineer/Inspector9444492 <br /> 8448388 Signed: <br /> Ist—Permittee 2nd—File 3rd—Finonce 4th—Utility/Street <br />