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f 'I CITY OF STOCKTON 74042 DEPARTMENT i APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY M5 Applicant's Name _ U�T 1` Date 6.19.1 APPROVED: BY THE PUBLIC WORKS DIRECTOR (Owner/ContractorSubject to the General Provisions and Special Conditions, Address la,r Phone S�0•h 3(o.3o3�f and all work must conform to the project's approved Storm City Or,+klowd _State�—lip Ctq&0`7 Water Pollution Prevention Plan or the most current version i �� "� of the City of Stockton Storm Water Pollution Prevention Location of Proposed Work, etc ' ytncn G()es� oIn � Mainten e Staff Guide,which er is applicable. OAWSo,rFx. s, Owner/Contrac4or Address$��a,bov.r y Dat Estimated Starting Date�t�no. o?DJ� Completion Date 8�' adl� Permit Expiration Date��"��-- i I I (or We) hereby apply for an Encroachment Permit to carry out the following work: ob r` L tQ+i J t)1 sY-Svbc 'rDr on behalf off' T or zers ill P, ��n Co �ro Fei 4Z �i4 AF veli �oca Dn, w I -� t p,tsli kc�tnol h� ct n 45 loo-1 Sb A, Sltita.(1 cGanl v, r rocl wi 16� �� USina14 �o er loca�ibn. All Bonn s ill b� route fh artc� i W/ V 3 r/'n ATTENTIO :Applicant/Con rac or-you are responsible tc regvr'� n -Y r �ctdrtd in a� w '``'� r replace all broken,damaged,and/or raised sidewalk,curb and PERMIT FEE......................... $ oL gutter from score mark to score mark adjacent to the parcel; -MCN Fee.......... $ remove USA markings upon completion of the permitted work. f J f LThe above named applicant hereby requests permission to: C-9-3 $ #61Set &44ac ted urs fDr S l2. in Fie. r,' Ivy-e al-41 'ou cc�'�n, TOTAL DEPOSIT ...... $ c� 4 971(.t)es� ah � / A Building Permit No, , Li/ Qdd{`,t�b/hc�.0 e/provrsionj�/ Improvement Plan No. r,Q d RL�o �LDI sildt. �G�e Supplemental Conditions* �- �OI�D✓IS rS�loWn� � 6 � on COII tr0/ IVO' 1�/t r^esoH5, Work i'lor ► or So,J i st` op -&d a,d 3rd )ERMIT NOT VAUD WIT&'�our A �+t 1 L ANTROL NUMBER. Y2e�S, t�4 Olt, 1�l��• ALL (209) 937-8366 TO REQUEST A CONTROL (UMBER NO LESS THAN 24 HOURS, BUT NOT IN _XCESS OF 72 HOURS PRIOR TO START OF WORK. Show sketch above or refer to drawing submitted 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 THE ASSIGNED 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 BEFC E IGi�IN Signed: Phone: i 15'-Permittee(white) 2nd-Inspection (pink) 310-File(yellow) 41h Finance(white)