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CITY OF STOCKTON _ 765 11 <br />CD PUBtM WORK& DEPARTMENT <br />APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br />Applicant's NameVQ? Date <br />(0wner/Contracto �. <br />Address lfl � i'l9byLAY or- r% Phone($ 139`410 <br />City 6. BOO" _)At" - -.- State 6A Zip '11570. <br />Location of Proposed Work, etc. 2.2 59 Aivro" wky, enl! <br />cD <br />APPROVED: BY THE PUBLICIVORKS DIRECTOR <br />Subject to the General Provisions and Special Conditions, <br />and all work must conform to the project's approved Storm <br />Water Pollution Prevention Plan or the most current version <br />of the City of Stockton Storm Water Pollution Prevention <br />Maintenance Staff Guide, whichever is applicable. <br />�vt�tcArit 2 tJ.Ec,st�j{ �r�iceZe A�ir77r(� <br />owner ontra o ress <br />Estimated Starting Date 10 �{ A Completion Date '►'i�1iZi Permit Expiration Date_ +7i�1 S�� <br />I (or We) hereby apply for an Encroachment Permit to carry out the following work: �eCf 0114+1 dt-C, <br />E+L,A�-t`i'er' �+ll%�� ��L �VY.sw �� iii � K�.� ���' �. _C�?��,��• f. � RrVLa�tc:L <br />iu t,, cn 6j&e.c ct a ` <br />ATTENTION: Applicant/Contractor — you are responsible to <br />replace all broken, damaged, and/or raised sidewalk, curb and <br />gutter from score mark to score mark adjacent to the parcel; <br />remove USA markings upon completion of the permitted work. <br />The above named applicant hereby inquests permission to <br />ID 1 b <br />r <br />Show sketch above or refer to drawing submitted <br />PERMIT FEE ........................... $ <br />AcMional..F-ootageFee .1<7'# $ <br />Sewer-T-ap Depaslt........ cm $ <br />TOTAL. DEPOSIT ...... $ <br />Building Permit No. <br />Improvement Plan No. <br />Supplemental Conditions: <br />Z3 <br />5'7:Q I lour <br />CONTROL NUMB. <br />CALL (209) 937-8366 TO REQUEST A CONTROL <br />MM ER NO LESS THAN 24 HOIJRB, BUT NOT W " <br />EXCESS OF 72 HOURS PRIOR TO START OF WORK. <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 HOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OFA 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:Pku Le Phone 6 9�?--h C <br />we ze 61 Wftms KELg4x t*)c <br />