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CITY OF STOCKTON 0 7 1 0 3 4 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's NameAty�q%Le4 &yFnvi'vanme„kI Date APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> Address S3� ,gfX'ti,t_ HCl. Phone t/61-160VSubject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> city Apl*n State (241 Zip 95:9 f.S- Water Pollution Prevention Plan or the most current version <br /> of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. in bu d t• t Maintenance Staff Guide, whichever is applicable. <br /> �///Owner/Contractor Address,. l } y i�c�` By Date <br /> Estimated Starting Date 3 1'108 Completion ate Permit Expiration Date S O� <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: it nto <br /> ,f2c u v ►-ct c ., G hmxwr ,' rl <br /> n-/ r `= x.11 /79 u 1J-i1 <br /> (�n <br /> ea A <br /> /1 d tuaxj aio, � 1h.) 6� but ° <br /> la e/ 4, yoto- <br /> ATTENTION: Applicant/Contractor-you are responsible to <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ <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 /> ii <br /> I 1 f i,5c- sty +f a-t� ev{ t�VQw(�k TOTAL DEPOSIT ...... $ �3°l Ofj <br /> P Ivi// t(4 in -ks 44U le;�f�� � �,, Building Permit No. <br /> J ✓ J ` Improvement Plan No. <br /> m,� .�nsf £�'�'S�-roc-� ruG'r►-• �� 646vn-eb- �l <br /> Sbultl AVP0,,4 LL) 01101 cREct�f zr� Sty 0 Supplemental Conditions: <br /> 12'111 k+ C4 PERMIT NOT VA'LID WMOUIT A <br /> CONTROL NUMBER. <br /> CALL (209) 937-B366 TO REQUEST A CMITROL <br /> NUMBER NO LES&.THAN 25 110URS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OE INORK. <br /> Show sketch above or refer to drawing submitted �� ��" ^•=A-� �-�� -�- -=mom= _�- -.---n• <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 /> Signed: JPhone: <br /> ord CII.. Ath _(=in onro /nihitol <br />