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I • • <br /> CITY OF STOCKTON 63742 <br /> DEPARTMENT OF PUBLIC WORKS <br /> AZ# APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name AAVM.K-F_D C]E06-W�RYYM1S�k1 Data it" IL5 "�7 <br /> (Owner/Contractor) quo- <br /> Address 1803 41 14� A LN $11C"t Q$7Q-1 Phone <br /> APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed Work,etc. <br /> 424 Vea.t +Pgy- s;nlU cr <br /> Owner/contractor Address By Date— <br /> Estimated <br /> ate —Estimated Starting Date lie 45 Completion Date t2 — ti — q-57 Permit Expiration Date <br /> (or We) hereby apply for an encroachment permit to carry out the following work <br /> C�mtJc>114 r� fAny-AA ciLV.kA lAC15 lt)lM� tt'A 01 2xcr - T)F ^ Dain <br /> RA 015 14• <br /> The above named applicant hereby requests penn.tilon to- / <br /> PERMIT FEE.:................... $ 17n _ <br /> Additional Footage Fee............. _ <br /> Sewer Tap Deposit ................ <br /> TOTAL DEPOSIT......... $ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <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, 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 to comply will be cause for revocation of permit. Applicant aijrees 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(1-800-842-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL(209)937-841124 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 /> f 1 "_"�'�V� ` Phone 09 ' <br /> Signed: ) "____ -__.___ ' _. _ <br /> w—Permittee 2nd—File 3rd—Finance 4th—Utility;Slreet <br />