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CITY OF STOCKTON 74619
<br /> PtMUt64MWS DEPARTMENT
<br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY
<br /> Applicant's Name an , Dated S`Pt?otl APPROVED: BY THE DIRECTOR
<br /> (Owner/Contractor) 11 Subject to the General Provisions and Special Conditions,
<br /> Address 111__ ��c.'^?`i� �D Pl�r Phone and all work must conform to the project's approved Storm
<br /> City ^0*.Y,10.AJ State CA -- -Zip Water Pollution Prevention Plan or the most current version
<br /> tw of the City of Stockton Storm Water Pollution Prevention
<br /> Location of Proposed Work, etc. ),0,i-,4teA W$ Maintenanc Staff Guide,whichever is applicable.
<br /> } t!1 ��Si 1r.)Or4t> bt con�,�cie� in r,4i•o. . ,,a v t crSY a
<br /> d g� ¢e �� j+c rui sir rid U, u};f r{ " Sy ✓ , ` y�- —=ate
<br /> Owner/Contractor A%ess �,r t ___. X
<br /> Estimated Starting Date_2L . t2o l_ Completion Date )�dct I Permit Expiration Date
<br /> a-C-+;v,'4ieS Sept
<br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work:
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<br /> �e rov3K� �n ca[co ttY i�. y - �.,rcr►�wls. C r�ztc will lie oc �rc,d ,, a ccot�avrce-Jt y't1-c;iy;n5 for u,tc?rz
<br /> ATTENTION: Applicant/Contractor-you are responsible to }•���
<br /> replace all broken, damaged,and/or raised sidewalk, curb and PERMI FEE,...,.................. $ _
<br /> gutter from score mark to score mark adjacent to the parcel: ,�G 1't q 9 93
<br /> remove USA markings upon completion of the permitted work. c e Fee.......... $ _
<br /> The above named applicant hereby requests permission to ,,.. $
<br /> TOTAL DEPOSIT ...... $ )144
<br /> U
<br /> Building Permit No.
<br /> Improvement Plan No.
<br /> 013A9 so �-}e�c hon St, Supplemental Conditions:
<br /> No-iC V-vva-i re7-Le- ons-f-
<br /> s; PERMIT NOT VAUD WITHOUT A.
<br /> CONTROL NUMBER.
<br /> �re&A-" (.v\c��^� i n if-r�efen Ce a /t CALL (209) 937-8366 TO REQUEST A WNTROL
<br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT ,
<br /> c6e- iz-rce-e7'. EXICESS OF
<br /> Fr72 HOURS PRIOR TO START OF WORk
<br /> Show sketch above or refer to drawing submitted C "'N "'"'"'
<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)937-8411 FOR SPECIFIC
<br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTI NIF
<br /> 11,
<br /> ED 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:ET e:-Permittee (white) 2""-Inspection (pink) 3111-File (yellow) 4111 -Finance (white)
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