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205 907 6901 P.02 <br /> w. : i I C WORKS PERMIT CENTR L� <br /> 'mss T`PCB-07-1955 21 �` <br /> CITY OF STOCI(TON <br /> DEPARTMENT Of PUBLIC WORKS Y <br /> APPLICATION poR ENCROACtiMENT ON Pll8L1 - N0 Fj 3 <br /> 13 2 <br /> tYl t i at <br /> L/ <br /> . Applicant's No I <br /> lat.rter/CentractorJ Pfione <br /> addras APPROVED: DIRECTOR OF PUBLIC WORKS <br /> Laenr;en <br /> of Propojsed woric.et `ter <br /> lconrractor Addre" <br /> Permit Expiration Dote <br /> Fuimorad Starting Gate s 1L�� =completion Date- <br /> I [or Wei hereby apply for an encroachment permit 10 car out the following work: <br /> tC"— �� l �'r L'-- <br /> The above named applicant hereby requests permission to• PERMIT FEE ....,. ............ <br /> Addirionai FWQQG Fee. .. <br /> Soutar Top Deposit ........................ <br /> TOTAL DEPOSIT ..................... .. 3 `� <br /> Building Permit No. <br /> Improvement Pian No. . <br /> Supplemental Conditions,- <br /> She- <br /> onditions,Spew si<o+cl+above or refer to drawing submir•.ed •f J� <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordincnres, <br /> resolutions, standards and specificetions currently in effeC, 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 eevocafron of permit. Appli- <br /> cant agrees to indemnify and hold the City harmless against any and all losses, costs, or darnages 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'perforrned under this <br /> permit. Certificate of insurance will be presented by applicant upon request. <br /> Road General Provisions an reverse side of this permit before signing. 'Note requirement of notifications and Inspections. <br /> Permit Engineerlktapector <br /> 9444250 <br /> 844.836$ Sian"! pt,ans _ <br /> r PERMITEE SMALL CALL 937-8412 <br /> f <br /> 151--permittee zn24 HOURS PRIOR TO START OF <br /> d_.Fi�� �r�F,,,an�e .tr,�ut�.rYrStreet `� ice. y' JORK FOR A CONTROL NUMBER , <br /> AND, <br /> TO SCHEDULE INSPECTION <br /> FFR— 7—cis TIIF 1 }Gi r}ra❑ nz Dan , rs z., <br /> T07AL P.06 <br /> FEB — 7-95 TIJE 1 <br />