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OOA CITY OF STOCKTON 64378 <br /> DEPARTMENT OF PUBLIC WORKS <br /> AZ# APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> t <br /> IT Ga i-po 1,4 iao►►. Date 412;L/9+ <br /> Applicant's Name --- <br /> (owner/Copra 4o(ahes 5140 t__ Phone '916 361- 6}3. <br /> Address _ <br /> Q er, APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of Proposed Work,etc. <br /> Nortk of J040 W W4sh(t10J'A S�j�t'e� r S 4 toh <br /> Owner/Contractor Address L�F1Sch 6NV40 thiol ey___ - Date 4 . 22 ' 5 <br /> Estimated Starting Date • -s1 9} Completion Date 2 SS g --Permit Explretlon D1ale S ,5 <br /> I (or We) hereby apply for an encroachment permit to carry out the following work: ri(l t kFt e t 3 <br /> sod 140trims Ih ke ctivtx I Ston tali hi kt- o - Wqu hoir-K of <br /> tke Wes? WAshihytclt s veer 1-044 Sarfact Strelt <br /> vtK fke. P r a dross ' t'ke wQs-r. Scd( 6ol-fngs will 6e <br /> I ' -L - ihck ily dia►Ketf'r Kh nkproKit+7�t�1� t5 feet deet/ C=oIIowl'h9 <br /> soil vivi.4 itawKowsiter l' from tke orifi s e wilt be <br /> -�j'lle y,)iFk a Ce�eht ahl Qkto i1C grow Oh �' G S9►ME day <br /> The above named applicant hereby requests permission to PERMIT FEE..................... $ <br /> Additional Footage Fee............. _ <br /> Sewer Tap Deposit ................ <br /> TOTAL DEPOSIT......... $ TZ lg <br /> Building Permit No. <br /> Improvement Plan No. <br /> ``Supplemental Conditions: - <br /> fIAV1� }r ?sCl %Ord5 4S�G1� <br /> U ' v <br /> be bkock-rcl aA arw\ -r me <br /> 5 dLrArn *rip-, cojece- 04 -�h« <br /> Show sketch above or rarer 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 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. 0 <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)931-8411 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: __�•_.. �/T('�[4� �--__. <br /> Phone <br /> tsl—Permillee 2nd—File (\v - 3rd—finance 4th-1.101ay/Street <br />