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a <br /> ZO <br /> CITY OF STOCKTON <br /> 6436 1 <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name AA t Cy" ]r t1 v i N(/ Kt+N ralate 4-5-1877 <br /> (Owner/Contractor) <br /> Address 1103 W. M a Inc� �- 5��, r S)oe-fA Yo phone 526 —0 l6 <br /> Location of Proposed Work, etc. 700'111 ��Q N Yc( fyo vctd ct Z, APPROVED: PUBLIC WORKS DIRECTOR <br /> 100i5 Aiq&j Wty F1100 i-I}00's Flora 51r<cC <br /> owner/Contractor Address By <br /> Estimated Starting Date Completion Date 9 Permit Expiration Date S ' �Q ` g 7 <br /> I (or We) hereby apply for an encroachment permit to carry out the following work : e5 I r(tc Io Ul <br /> Of' e r <br /> 1410rt` or)vt W' 13 xsJ0Gt6 1 4 <br /> r. wig ' oY, -e uhatr �0utn 5TDPq e <br /> Ta—ti ! e- S<a 't'7'a e k i M/r0 r K Q <br /> The above named applicant hereby requests permission to• <br /> PERMIT FEE......... .......... $ L <br /> Additionat Footage Fee. <br /> Sewer Tap Deposit ............... q <br /> TOTAL DEPOSIT......... $ Z <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Q li<e--ep -1 <br /> Show sketch above or refer E drawing submittetl <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, and to pay to City its actual cost for removal and proper replacement of any item which <br /> does not meet above requirements. Failure 10 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 of 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 (1-80044.2-2444) 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 /> Read General Provisions on reverse side of this permit before signing — Note requirement of notifications and inspections. <br /> Signed: 1 _ —. Phone 156 —D Z 6 1 _ <br /> tst—Permittee 2nd—File 3rd—Finance 41 h—U10ity l Sheet <br />