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• ! �,,�. o53obo <br /> S CITY OF STO71688 <br /> PUBLIC WORKS DEPARTEPART MENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> r <br /> Applicant's Name'� r O� "'L�• Date VL_ APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) . nn \�(o �6\ 04� Subject to the General Provisions and Special Conditions, <br /> Addres/s���� 110 M l`0 Phone r and all work must conform to the project's approved Storm <br /> City `��nC.-1•�q CGr�PV State$ �_Zip b (3 Water Pollution Prevention Plan or the most current version <br /> GG 1 of the City of Stockton Storm Water Pollution Prevention <br /> ' <br /> Location of Proposed Work, etc. Y�y r10.r \ (Z A" Maintenance Staff Guide,whichever is applicable. <br /> By /�/d�i/ l2 23`7 <br /> Owner/Contractor Address Date `J <br /> Com lebon Date )--w'-0 Permit Expiration Date �"-/ O .3 <br /> Estimated Starting Date ��1 P <br /> The <br /> 1 (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> 1.c c� r tti�t of wo <br /> t �rev MU �.\or� �`� W Cl S �I^ <br /> (1�vr hlc Qe�r,�x Cs`� ?S \,J <br /> Ung -2 R 2007 <br /> ENVIP ;;,jMIEN c T.A;Tu <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 .......... $ <br /> The above nan ad applicant hereby requests permission to: Sewer Tap Deposit.................. $ V <br /> i• <br /> SqG TOTAL DEPOSIT ...... $ <br /> Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT NOT VAUD 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 /> CONTROL# <br /> Show sketch above or refer to drawing submitted <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 THIS PERMIT, PERMITTEE SHALL CALL Y W B <br /> RK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE <br /> SIDE <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. (+� c� <br /> Signed: / one:"1 1�- 11�\'06OJ <br /> r-,-c��\ SiiV�C� <br /> P <br /> 1s'-Permittee (white) <br /> 2nd -Inspection (pink) 3rd -File (yellow) 4'h-Finance (white) <br />