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CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT 74450 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> J�� �/tc. <br /> Applicant's Name &Oaw•C() (j�o��lt)t `ti`W1�Date 7-I `I APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/C r cto I� \\ 77 <br /> Address _ J ULc rJ Phone 20 L)�7 I O, Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City��L�CW State C Zip Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. t p5 (i 6,� or. Ea f S' of the City of Stockton Storm Water Pollution Prevention <br /> Maintenance Staff Guide, whichever is applicable. <br /> Owner/Contractor Address 937 5 .oad S�,,Ic{zt.,. C� Sal By V "( " <br /> � l� 6� Wiwi i `' Date I <br /> Estimated Starting Date mpletion Date YO I-t,wlUuv ermit Expiration Date 0 <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> �w��ww r ►moo ✓I i w e e is �; I h� r 1 h w <br /> r j r kcur ; — c, P `NQS 4 t c 6 fr✓c+.-J <br /> 5 �k w I R'' j 10110s 4 a I ,'fit c <br /> Gt C IM c (1 ✓ 116 C 64-j"� C <br /> ATTENTION:Applicant/Contr ctor—you are responsible to <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE............. $ 00 <br /> .............. <br /> gutter from score mark to score mark adjacent to the parcel; -J`7 <br /> remove USA markings upon completion of the permitted work. ��igga�otage-Fue ..........`.. $ 2� <br /> The above named applicant hereby requests permission to <br /> -Sewer-Tap-E eposit.........C... $ �� <br /> TOTAL DEPOSIT ...... $ r 2 <br /> Building Permit No. <br /> .rte Improvement Plan No. <br /> Supplemental Conditions: <br /> PER,MHT NOT " 0 WMHOUT A; <br /> or ct CONTROL NUMUER. <br /> CALL (209) 937-8366 TO REQUEST A CONTROL <br /> NUt•:,LEIR NO LESS I'li .N?4V HOURS, CUT NCT !N <br /> EXCESS OF 72 HOUIRS PRiOR\TO ?: S\,i-Gi='�`'tCc::i. <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 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: Phone: / �%V �� / oo <br /> lsf-Permittee (white) 2nd-Inspection (pink) 3rd-File (yellow) 4th-Finance(white) <br />