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92/25/2065 16: 14 1 HORIZON _ PAGE 02 <br /> r <br /> • CITY OF S'TOCKTON <br /> PUBLIC WORKS DEPARTMENT 6 9 1 5$ <br /> M9 APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> M5 <br /> Applicant's Name /{a /ll�d1{� t1YA`20�f1 klate -Q APPROVED: BY THE PUBLIC WORKS 131RECTOR <br /> Address r ��"- C Phone !Iv 2�7� subject to the General Provisions and Special Conditions, <br /> and all work must conform to the projects approved Storrs <br /> CityE/12C72da 71J1115 State CA Zip 576 7-__ Water Pollution Prevention Plan or the most current versiolI <br /> Location of Proposed Work,etc.Z7 55 �od[ Ati7Y of the City of Stockton Storm Water pollution Prevention <br /> Mainten Staff Guide, hi h6 is applicable. <br /> �erAContracto Address Ii•�•F/rrl�i 1 �: � �y Date <br /> Estimated Start g Date I-f7'-0 S Completion Date _ _�ZI-1J,� Permit Explratlon Date <br /> I(or We) hereby apply for an Encroachment Permit to carry out the following work; r1jt'�,w, r'H-Sf4Jct ►t _.ar <br /> ATTENTION:Applicant/Contractor-you are responsible t0 <br /> replace all broken, damaged,and/or raised sidewalk, curb and PERMIT FEE ...................... $ Z <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 /> Thr aha—namad appGe3nL naroby raquoM parmhislon to: <br /> Trench Cut Fee...................... <br /> �, i Sewer Tap Deposit ........ $ <br /> 1 �� TOTAL DEPOSIT — ,, $ %36 <br /> / r+g Permit No. t <br /> Improvement Pian No. <br /> f <br /> Supplernenta!Conditions: ' <br /> PERMIT NOT VAUD WrIMOUT A <br /> CONTROL NUMER. <br /> CALL (209) 937-&W TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOLM, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> Show sketch abmeOfWar ftdrarringeubMFa*d CY1y+ l�► A <br /> �p1 <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of We permit,as walIVajs7a]I applicable C1ty ortlinanres,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 /> PERfM]rfTEE SHALL CALL(209)937-8365 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS,PRIOR <br /> TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT. IF <br /> WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL_NUMBER,THE CONTROL NUMBER WILL BECOME <br /> INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER. (FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION � <br /> INIPROVEMENT8,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-641'1 FOR SPF-C1FIC <br /> INSTRUCTIOHS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Signed: 7;['4,''� <br /> 9 phone_ <br /> E•'!'�( �t.� as oxtv�.e�: [1� � i <br /> 1gt-Permittee (white) 2"°--Inspection(pink) 3r°-File(vellow) 4"h-Finance(white/ <br />