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CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name 6 r fin/ «� " c71Date dl--71.i0wri `l 60194 <br /> Addy r/Contracfor) 456 Y <br /> Addres Phone ' <br /> Location of Proposed Work,etc. APPROVED: DIRECTOR OF PUBLIC WORKS <br /> �� // <br /> Owner/Canrroctor Address By - _ Date <br /> Estimated starting Date <ZR Completion Date ��j �/ Permit Expiration Date <br /> I {or Wei hereby apply for an encroachment permit to carry out the following work: j,/f l� <br /> Pte ,'-t= -The above named applicant hereby requests permission to - PERMIT FEE.. 3 S <br /> Additional o <br /> SeW�r Tap Depo t,.-.C ✓L 'IG <br /> � <br /> q <br /> L'REPO T ... $ <br /> F0, 1,g <br /> "Building� Njgq40 �J <br /> Improvement CPf / <br /> Supplemental Conditions: <br /> �:S a'�c•�i cXc� GtJ/��c+moi ? <br /> Show sketch above or refer to drawing submitted v <br /> I <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 signirtig. eq re to notifications and inspections. <br /> Permit Engineer/Inspector <br /> o � <br /> 944.8366 Signed: <br /> Ist--Permittee 2nd—file 3rd--Finance 4th—Utility/Street <br />