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CITY OF STOCKTON <br /> w PUBLIC WORKS DEPARTMENT. 73855 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> r J1� <br /> Applicant's a_ loodr.J .F �:I�.v.� pate APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owne I <br /> Address d• o Phone 70�- �o Subject to the General Provisions and Special Conditions, <br /> and all workmp <br /> ust conform to the ra ect's a roved Storm <br /> cityState 'Zip Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. _ l�D� t,oh� of the City o Stockton Storm Water Pollution Prevention <br /> Main Staff Guide,whichever' applicable. <br /> ZA <br /> f wn ontractor Add rear, vo-a- 12K beng yCA By <br /> Estimated Starting Date 1'J D Com 2 <br /> pletton pate Permit Expiration Date 7— <br /> I(or We)hereby apply for an Encroac ment Permit to carry out the following work: ��` <br /> II ATTENTION:ApplicanVContractor—you are responsible to <br /> ;t <br /> replace all broken,damaged,andlor raised sidewalk,curb and PERMIT FEE.................... .. $. rl <br /> gutter from score mark to score mark adjacent to the parcel; <br /> remove EISA markings upon completion of the permitted work. Additional Footage Fee.......... $ <br /> The above named applicant hereby requests permisalon to <br /> M f Sewer Tap(Deposit.................. $ <br /> TOTAL.DEPOSIT ....... $ <br /> �S 4jofa�`c9 <br /> ,,44w Building Permit No, <br /> Improvement Plan'No. <br /> If <br /> Supplemental Conditions: <br /> . aY <br /> PERMIT NOT VALID'WHOUT A <br /> CONTROL NU ER, <br /> CALL (249) 937-6W TOPEQUEST A COMiROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT It <br /> EXCESS OF 72 H TO)STRK. <br /> CONTROL# <br /> Show sketch above or refer to drawing submitted I - , <br /> Al <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 INSPECTIONS,AS IDENTIFIED ON THE REVERSE <br /> SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937-8361. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Signed: <br />