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CITY OF STOCKTON <br /> 64398 <br /> (DEPARTMENT OF PUBLIC WORKS - <br /> AZ# APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Appfican' CV <br /> ,Owner ntrac <br /> Address phone <br /> Location of Proposed Work,etc. CRSr Ic uF !qn A Pn Wit PUBLIC WORKS DIRECTOR <br /> u1s�r_h±.Rtn .,.,¢A^el'Ft'1� 4Av� CAn, : <br /> Owner ntractor ressI V W Jit 1�AC L # Date (1 4 <br /> Estimated Starting bate 05-Z7-4 �7 Completion Date - O t 4 __� Permit Expiration Date <br /> (or We) hereby apply for an encroachment permit to carry out the following work : �S•2i4i 4Yf, „,.Ll�9'M-J'A--C1 <br /> t 1^ W' lS r L n J /' t2 R <br /> �tE•ry � Preen vy a] - 1 L2 _T- <br /> The above named applicant hereby requests permission to- $ � <br /> PERMIT FEE..'...��.1.:1..,...,. ... <br /> Additional Footage Fee............. 'fir ''' ''f <br /> Sewer Tap Deposit ..,.... <br /> W ' r <br /> TOTAL DEPOSIT......... $� <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: ,'.. r40 s <br /> 444-Q c6-D <br /> - , <br /> Show sketch above or refer to drawing submitted 1` <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances, resolutions, 1; <br /> standards and•specifications currently in effect, and to pay to City its actual cost for removal and proper replacement of any item which " J <br /> does not meet aboAl4equirements. Failure to comply will be cause for revocation of permit. Applicant agrees to 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 df or as a result of work to be performed under this permit. A certificate of insurance shall be submitted to the <br /> City Risk Manager prior to beginning construction. ( ' <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT (1-800 B42.2444) 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 /> i <br /> Read General Provisions on reverse side of this permit before signing — Note requirement of notifications and Inspections. L 1 t <br /> Signed- - - Phone Za9~ -! 6 <br /> rsl--Permittee 2nd—Fite 3rd—Finance 41b—Utility!Street <br />