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5PUBLIC CITY OF'S DEPAR 71690 N -52o5)o6z WORKS DEPARTMENT n APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY 4W 07.2,L11 Cin l \ Applicant's Name �X Date - APPROVED: BY THE PUBLIC WORKS DIRECTOR (Owner/C trac r �R Q phone- llL'01'-'�-\� Subject to the General Provisions and Special Conditions, Address 196 and all work must conform to the project's approved Storm City \\CS.6O(9r&0VV, State C—A Zip 'G(;)rJ Water Pollution Prevention Plan or the most current version Location of Work etc.Proposed of the City of Stockton Storm Water Pollution Prevention P 1 X11 N Maintena tall Guide, whichever is applicable. Owner/Contractor NAY G By G Estimated Starting Date Completion Date �G -L (j Permit Expiration Date I (or We) hereby apply for an Encroachment Permit to carry out the following work: 1_V-< 1 ^SkG,\ka Or' OLS w 6 1 1 r , C, -1 R,', W q ATTENTION: Applicant/Contractor-you are responsible to G Or replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ gutter from score mark to score mark adjacent to the parcel; remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $ The above named applicant hereby requests permission to Sewer Tap Deposit.................. $ TOTAL DEPOSIT ...... $ t � 14 mit No. 4127- 744v Improvement Plan No. Supplemental Conditions: PERMIT NOT VALID WITHOUT A CONTROL NUMBER. CALL (209) 937-M TO REQUEST A CONTROL NUMBER NO LESS THAN 24 HOURS, BUT NOT Ir EXCESS OF�72 HOURS PRIOR TO START OF WORK. Show sketch above or refer to drawing submitted CON--rrq�OL — —"— 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 indemnity 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 BEFORE SIGNING. �1(6-W�013 Signed: Phone: ts•, _Pr rmittPa lwhital 2n6 -Inspection (pink) 3rd -File(yellow) 4'h -Finance (white)