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t.-j--' • ON • f1 <br /> CITY OF STOCKY � ,.,• Q 4 1 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name <br /> ('�,1c; vtTS DateAPPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Co tractor) �, Subject to the General Provisions and Special Conditions, <br /> Address SU' Phone 6 N'X%5- 'L70o and all work must conform to the project's approved Storm <br /> r+�,I[f, State CSA Zip� _ Water Pollution Prevention Plan or the most current version <br /> City -- _---_ -- of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work,etc. tv3u <br /> Ak: 16ei-We en fi"t 191-- Maint nan Staff uide,whichever is applicable. <br /> C� � By Date <br /> Owner/Contractor Address X�l J <br /> Completion Date iF�� �'� Permit Expiration Date Z 2.q <br /> ! <br /> Estimated Com <br /> f1 ,\C Starting Date 1�i`F�bt it p <br /> �I C itCll s ay t t3 t`7�i 42r <br /> 1 (or We) hereby apply for an Encroachment Permit to carry out the following work: <�+ (nr^ <br /> �/t• ..�+�� v(Mv^R+1 rSoc�t� i _� tY r^ � Ia,JCa rl! (r <br /> )IjAq ►/1• F. 11CL:1 �/1t edIC l? <br /> nL Al l'I;kC, "e1 V Ir 4 <br /> t vLt'J-W <br /> t l Sf In >� . fer „ ll be. rrtccf�rc�cRnc , <br /> �• S(1 ' .tn C cr C tti fc C� ��� ctivtt Ir t <br /> a� <br /> 4- 1 ��C-i��1 i�, ►^v_�c.11 ex'rs1�ro r LQ_�I�. <br /> ATTENTION:Applicant/Contractor—you are responsible to -. <br /> PERMIT FEE..j <br /> replace all broken, damaged, and/or raised sidewalk,curb and 9 Z� <br /> gutter from score mark to score mark adjacent to the parcel; <br /> remove USA markings upon completion of the permitted work. Fee.......... $ ' <br /> , n S /© ` u I <br /> The above named applicant hereby requests permission to: SeuueW-Tap-(J.0PQ6�t.................. <br /> I l/O <br /> TOTAL DEPOSIT ...... $ CL7 <br /> I Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> FERN IT NO'S'VAL1}0 WITHOUT A <br /> CONTROL AMBER. <br /> CALL (209) 937-8366 TO REQUEST A CONTROL_ <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> Show sketch above or refer to drawing submitted <br /> ith all as well as all <br /> IMPORTANT.dardand SpecificationspApplicant <br /> hereby agrees <br /> currently in effect,comply ancJ t paytothe City ovisions fits ia tualtcost for removal applicable <br /> dlproper replacement of anyitemwhich <br /> Stan will be cause for <br /> does to meet h above requirements. <br /> equire any ci ntll . Failure <br /> costs,omdamages resulting from injury tto persons,death of persicant on agrees <br /> damage o property <br /> of <br /> the u y <br /> occurring at the site of,against <br /> 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 /> PITAL IMPROVEMENT <br /> OJECTS OR <br /> E SHALL CALL FOR A NEW CONTROL NUMBER. <br /> CA <br /> BECOME INVALID <br /> R VEMENTS PEIRMETTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 8FOR SPECIFIC <br /> SUBDIVISION <br /> INSTRUCTIONS <br /> EPRIOR PTO THE BEGINNING OF ERMITTEE SHALL CALL(ANY <br /> W RK.) PPRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERS <br /> SIDE OF THIS P <br /> 1. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Signed:0i, <br /> Phone: <br /> 151-Permittee(white) 2nd-Inspection(pink) <br /> 3`d-File(yellow) 01-Finance (white) <br />