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of OwO <br /> • CITY OF STOCKTON • 71689 <br /> S PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT (N <br /> IENT ON PUBLIC RIGHT-OF-WAY n. ,y0�.1�()J <br /> Applicant's Name )�CV\1�11�etoa�,u�a� �\( Date l lP Q7 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) (� I / _c;� I _�O� Subject to the General Provisions and Special Conditions, <br /> Address 3UIl �('�hOre Qt Phone 1e OGS! and all work must conform to the project's approved Storm <br /> City \t�r`Clro CO(�(�ti C. State�—Zip ,7b Water Pollution Prevention Plan or the most current version <br /> OT the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. Maintenance Staff Guide,whichever is applicable. <br /> ei -� 136 pei(`ty Ave- _�`C7 <br /> Owner/Contractor Address By Date <br /> Estimated Starting Date Completion Date — - o Permit Expiration Date <br /> I (or Wel hereby apply for an Encroachment Permit to car out the following work: j ,\ 1 S�c <br /> Vif <br /> c5 VrA <br /> ATTENTION: Applicant/Contractor—you are responsible to ®, <br /> replace all broken, damaged, and/or raised sidewalk,curb and PERMIT FEE........................... $ ! �� <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.......... $ 4.- <br /> The above named applicant hereby requests permission to <br /> Sewer Tap Deposit.................. $ <br /> r. <br /> TOTAL DEPOSIT.... <br /> .. .. $ )'7 3� <br /> ,Bsilii Permit No. y 7 Z 7L—' <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT NOT VALID WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 937.8386 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 todrawing submitted CONTROL# <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.Acertificate 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 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��— Phone: <br /> Mie�s1 CxjGrl.ei <br /> 1s' -Permittee (white) 2nd -Inspection (pink) 3rd -File (yellow) 4m -Finance (white) <br />