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CITY OF STOCKTON 64 -199 <br /> DEPARTMENT OF PUBLIC WORKS <br /> AZ# APPLICATION FOR ENCROACHMENT ON PUBLIC RIOHT OF-WAY <br /> Applicant's Name +v rc��hl em Date a <br /> (Owner/Contractor) <br /> Address / � - Phone x )'? <br /> S�.� �� ��® .�.. APPROVED: PUBLIC RKS DIRECTOR <br /> Location of Proposed Work,etc. <br /> Owner/Contractor Address By —9 Date <br /> Estimated Starting Date /" 2 + / Completion Date %2,%— & ` Permit Expiration Date �-" 1 —77 <br /> 1 (or We) hereb apply for an encroachment permit to carry out the following work: / <br /> 77 <br /> The above named applicant hereby requests permission to- <br /> PERMIT FEE..................... $ ----- <br /> Additional Footage Fee............. _ <br /> Sewer Tap Deposit ................ <br /> TOTAL DEPOSIT......... $ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> IC-e -7 <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 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. (40 <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-800-,W-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 /> Signed: <br /> �-�-`" - - ---- --__Phone--- -- <br /> 5ro� <br /> 1st—Permittee 2nd—File 3rd—Fin ce 4th—Utility/Street <br />