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1k <br /> #I. <br /> CITY OF STOCKTON , 7 1 0 9 3 <br /> PUBLIC WORKS DEPARTMENT <br /> MS APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> M5 <br /> Applicant's Name Date 2-ly-o8 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> Address Q�� __Chau) >2�,ad Phone��- Yip 1-Itt(y Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City g-Ir' is er) State 0,4 Zip 9=1 Water Pollution Prevention Plan or the most current version <br /> i of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. io ' y '; , 1 kek Ill, Maintena a Staff Guide,whichever is applicable. <br /> Owner/Contractor Address :7:� SCtiit �'�do�� ltk+.u, S' t' ' _ BYzvz12 Date <br /> Estimated Starting Date �_ Completion Date y�0 i./y`x Permit Expiration Date /f 15: _ <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: kj l <br /> T <br /> ATTENTION: Applicant/Contractor—you are responsible to <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ 3� L <br /> gutter from score mark to score mark adjacent to the parcel; <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee .......... $ <br /> The above named applicant hereby requests permission to <br /> Sewer Tap Deposit.................. $ <br /> �� QfC Lt►1Pc'/ S��r O� f' TOTAL DEPOSIT ...... $ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT NOT VALID WI 'HOUT <br /> CONT OL NUMBER. <br /> CALL (269) 937-8,%6 `?-O REQUES-11 H CONTROL <br /> NUMBER NO LESS 'I'HAN 24 HOURS, BUT NOT' <br /> EXCESS OF 72 HOURS'PRIOR TO START CIF WORK, <br /> Show sketch above or refer to drawing submittedi ------^- <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 the City its actual cost for removal and proper replacement of any item which <br /> does not meet the above requirements. Failure to comply will be cause for revocation of this 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 /> occurring 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 City Risk <br /> Manager prior to issuance of this permit. <br /> IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR SPECIFIC <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE <br /> SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937-8381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. ., <br /> j <br /> Signed: Phone:,�� �-i.�� " t� <br /> 1st-Permittee (white) 2nd-Inspection (pink) 3rd -File (yellow) 4th -Finance (white) <br />