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iI <br /> CITY OF STOCKTON h <br /> DEPARTMENT OF PUBLIC WORKS J AN O 3 1990 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> ENVIRONMENTAL WEALTH ' <br /> PERMIT 14 r1 . .�cc <br /> Applicant's Name !S% G C2 Date f--A r) 58451 <br /> I l <br /> (Owner/contractor) ! <br /> Address A Z L-. W' HAT—C14. /t!i Dp45S__rA Phone - <br />! APPROVED: DIRECTOR OF PUBLIC WORKS <br /> Location of Proposed Work,etc. 14A/IL9 L7G� - <br /> Owner/Contractor Address sy— f --Date <br /> Estimated Starting Date /— ---Completion Date / z" r ------Permit Expiration Date <br /> I (or We) hereby apply for an encroachment permit to carry out the following work; A%,2 Q+- ;, PE:A^,0UE u <br /> 2r F (AA=-WALu G(,4Ra * Ca,rma&• -+ ,2/a x Q, A- C. /Al-aNze)oy GiA6ar <br /> Sar` uJr/ i f3 _ ,=.r�.�uFt� 7D A 045EP7:H �� 'da � 7W — Excskrt�`J— rur�c_ g� ' <br /> Rh <br /> L (_ i <br /> The above <br /> above namedd applicant hereby requests perm ission to - PERMIT FEE .......................:........................ $ <br /> Additional Footage Fee.....___. .... ............ <br /> Sewer Tap Deposit ...__....-...- it r <br /> TOTAL DEPOSIT <br /> ........... $ I 1 <br /> i' <br /> Building Permit No. <br /> i, <br /> Improvement Plan No. li <br /> Supplemental Conditions: <br />'$a <br /> I! <br /> Il r <br /> i, <br /> Show sketch above or refer to drawing submitted II <br /> n ' <br /> IMPORTANT: Applicant hereby agrees to-comply with oil 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-$492 <br /> 944.8366 Signed: �' �(� Phone <br /> lst---Permittee 2nd--•Fi1e 3rd—Finance 4th—Utility/Street 9 <br />