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64124 <br /> CITY OF STOCKTON <br /> DEPARTMENT OF PUBLIC WORKS <br /> Aa# APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name '_ __ Date � -7 <br /> (Owner!Contrac or <br /> Address _ 0.3.__ A4AvrA Ae-ri Q A Phone !_ Z� <br /> SlaG1�.'TU� APPROVED: PUBLIC WORKS DIRECTOR <br /> Location of P oposed Work,etc. <br /> ion <br /> Owner/Co ntraclorAddress `?b3 ""�'~�► r A Bt Date <br /> 7 -140 / <br /> i 41��9Sr <br /> Estimated Starting Date / Completion Date J��G ermlt Expiration Date <br /> I (or We) hereby apply for an encroachment permit to carry out the following work <br /> a.�.ra art .3b E6-- 5z--1r M7- <br /> The above named applicant hereby requests permission to- 'r <br /> PERMIT FEE............... <br /> Additional Foolage Fee............. <br /> Sewer Tap Deposit .... r._ <br /> •r/Jt417 <br /> TOTAL DEPOSIT— $ _- <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Show sketch above or rater 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. (– <br /> PERMITTEE SHALL CONTACT UNDERGROUND SERVICE ALERT(1-80"V-2444) TWO WORKING DAYS BEFORE BEGINNING <br /> WORK FOR LOCATION OF UNDERGROUND UTILITIES. <br /> PERMITTEE SHALL CALL(209)937-8411 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 . `��^�/ �' _ Phone" — 4 1/ <br /> Isl—Perm'rllee 2nd—Fife 3rd.-Finance 4th—Ulility l Street <br />