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CITY OF STOCKTON 7 6 51' 9 <br /> CD DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> M5CD <br /> Applicant's Name Date � t APPROVED: BY THE DIRECTOR <br /> (Owner/Contraclo�, jL Subject to the General Provisions and Special Conditions, <br /> - ------- I{Lf04bkuy QR, Phone b � "� 1 <br /> � and all work must conform to the project's approved Storm <br /> City , D d{C0W State 6-14 W Zip air 7(o.?• (Nater Pollution Prevention Plan or the most current version <br /> S of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. 2.2 t%y�11i%FDti�" erT' er " ?i Maintenance Staff Guide,whichever is applicable. <br /> v►e; FARO-ntracior ress aft tj� Ckt(4t t�l�l�acJ � By �u/l1� � Date <br /> Estimated Starting Date 10 �` 1'7; Completion Date �4 Sri Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: �� <br /> ins tou i�s�t i W�� . I�Ve��d lvi w�,~ t-A' ►�. r r2,�.d�cd�c, t a�vi�e l c.t <br /> iU tr �► weGlee-LLi Zdu�c` w o► � Uc, �fe. <br /> ATTENTION: ApplicanVContractor—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. Aditlortal_FootageFt?e ..1L"t1 $ [ v� <br /> The above named applicant hereby requests permission to: <br /> Sewer-T p-Depaslt�.......C�..S $ �� -410 <br /> TOTAL DEPOSIT ...... $ 57 Q loQl <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: WW010I <br /> CONTROL MEER. <br /> CAL (209) 9374M TO REQUEST A 00WOL <br /> IUNMR NO LESS THM 24 FIRS, 60' NOT IN <br /> EXCESS OF 72 FO"PWOR TO START OF WMK. <br /> GMMM— <br /> V11 t01(ad -- <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 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)937-11411 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: UAkkLEC-tv Phone.gV' 9P--a7V <br /> 1C 'E17.@ 6-I EIN1000 k4a-X.LL PAC. <br />