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�r <br />: 1 CPT <br /> CITY Of STOCKTON I <br /> DEPARTMENT OF PUBLIC WORKS <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> N° 61580 - <br /> Applicant's No e - <br /> (Pam/controcta) � <br /> Add ns M�i �. Phone 57�i-�13� <br /> I Z1,59 ,tom �T i APPROVED: DIRECTOR OF PUBLIC WORKS' <br /> Location of Proposed Work,etc. r�c� <br /> O./Contractor Address --2<0 Ely trate <br /> Estimoted Stoning Date ��— S Completion Date 1-2 3 S' Permit Expiration Date z2— :2 �z <br /> I for We) hereby apply for an encroachment permit to carry out the following work: <br /> wXi e7 e <br /> �T�e Jacca `i�� o PGrn - � i' DDtaU� <br /> The above named applicant hereby requests permission to PERMIT FEE _ ......_... r <br /> S <br /> Additional Footoae Fee.... ..... .. _.. .. <br /> Sewer Tap Deposit .................................... <br /> 'i <br /> TOTAL DEPOSIT ........................ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> i <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 side of this permit before signing. 'Note requirement of notifications and Inspections. <br /> Permit Engineer/Inspector <br /> 944-8250 ��—�--/ C209)S7`/—a/3 <br /> 9448388 Signed �- Phone ., <br /> Ish-0ermiltae 2nd—lite 3rd—Firwnce efts—utlity/street - <br /> l <br /> ji <br />