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t '�eat <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> N° 52229 <br /> /Appl, s u LLSTQ}�S Date '7J0��-7 g <br /> Add- o dri,f1e -le 2 io Phone916-r,�,i��6! <br /> c'►C G t t ��� �� APPROVED: DIRECTOR OF PUBLIC WORKS <br /> Location of Proposed Work,etc. 1-I <br /> �3Owner ontroct Address By Date i <br /> Estimated Starting tion Date-m$" Permit Expiration Date <br /> —10 L2 <br /> I (or We) hereby apply for an encroachment permit to carry out the following work.—I)r.I <br /> Ain? Lri3 h monL +r+sr la! a1 i n ]�i� r# L -• —_ .' <br /> The above named applicant hereby requests permission to - PERMIT FEE................... Nr s <br /> ....... ................ f <br /> Additions Footage Fee. ..... ................. <br /> Sewer Tap Deposit .................................... <br /> TOTAL DEPOSIT ........................ <br /> �e 0,+. -Qche"' building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> � �. 45575 <br /> C(1p>YC-rL OLo14 <br /> Show sketch above or refer to drawing submitted <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 aide of this permit before signing. *Note requirement of notifications and Inspections. <br /> Permit Engineer/Inspector <br /> 944-6250 <br /> 944.8366 Signed: &22",2 4�49 <br /> _ —Phone <br /> 1st-permittee 2r>d•—file 3rd—Finance 4th—.Utility/51teet <br />