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i CITY OF STOCKTON 71781 PUBLIC WORKS DEPARTMENT APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY MM5 Applicant's Name Date�_ APPROVED: BY THE PUBLIC WORKS DIRECTOR W 14� .� s~1 Phone �� (�J -? fl Subject to the General Provisions and Special Conditions, Address and all work must conform to the project's approved Storm City 61 D � A�t State t Zip ��7z Water Pollution Prevention Plan or the most current version of the City of Stockton Storm Water Pollution Prevention Location of Proposed Work,etc. p 6tf Maintenance Staff Guide,whichever Is applicable. WAX 4 ILI C t �H k� 11 Y Dat tt�be Estimated Starting Date Completion Date 0 Permit Expiration Date I(or We)hereby apply for an Encroachment Permit to carry out the following work: ATTENTION:Applicant/Contractor-you are responsible to a replace all broken,damaged, and/or raised sidewalk,curb and PERMIT FEE........................... $ gutter from score marls to score mark adjacent to the parcel; yam_ remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $ The above named applicant hereby requests permiaslon to Sewer Tap Deposit.................. $ TOTAL DEPOSIT ...... $ 3' oa Building Permit No. Improvement Plan No. - A Supplemental Conditions: FERMIT NOT VALID WHOUT A CONTROL.NUM®ER. CALL (209) 037.8366 TO REQUEST A CONTROL DUMBER NO LESS THAN 24 HOURS, BUT NOT IP EXCESS OF 72 HOURS PRIOR TO START OF WORK. Show sketch above or reler to drawing submitted CON i ROLO IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit,as well as all applicable city ordinances,resolutions, Standards and Specifications currently in effect,and to pay to the City its actual cost for removal and proper replacement of any item which does not meet the above requirements. Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnify and hold the City harmless against any and all losses,costs,or damages resulting from injury to persons,death of person or damage to property 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 Manager prior to issuance of this permit. IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THEASSiGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937-8381. READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. Signed: L� Phone: t$ I 15t-Permittee(white) Zed-Inspection(pink) 31d-File(yellow) 41b-Finance(white)