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C7 <br /> CITY OF STOCK ON 7� - <br /> DEP ARTMENT 75093 , <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAYM05 <br /> . <br /> Applicant's me �/a7`f/4 L t'N �Nf/( ate.GI'l3� r APPROVED: BY THE PUALIOMOM&IDIRECTOR <br /> (Owner antractor <br /> Address v R/ Phone ��� �3y 9flS , Subject to the General revisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City AN—6-L00G._ _____- State GA Zip '75 9NV3 Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. Z3/S/V' GA 4,C±,-e1Vt A, �T of the City of Stockton Storm Water Pollution"Prevention <br /> Maintenance Staff Guide,whichever is applicable. <br /> 14 <br /> Owner/ ontraotar ddress By Date ' /�_// <br /> Estimated Starting Date 9� Completion Date IT, 3 / Permit Expiration Date �Z•3I 1 f <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following ork: <br /> G C-LL Ad.4 r,>o/Vt1i6-& T- oFMw -3 w -S AW -75 MOV - 7D <br /> 5 --o y a -3 d GLJ o 7-az a -lo <br /> ATTENTION:Applicant/Contractor-you are responsible to �- <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ <br /> � 3. <br /> gutter from score mark to score mark adjacent to the parcel, ? L <br /> remove USA markings upon completion of the permitted work. Additional Footagefee.......... $ <br /> The above named applicant hereby requests permission to <br /> G <br /> Seiver Tap Deposit................... $ <br /> TOTAL DEPOSIT ......, <br /> �l IVg --L--f BSI Iding Permit No.., <br /> ImF rovement Plan No. <br /> Su ipl6mental Conditions: <br /> PERMIT NOT VAUD.-WHOUT A <br /> CONTROL NUMBER. <br /> CALL, (209) 937-&W 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 CONTROk 1 <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this per nit, as well as all applicable city ordinances, resolutions, <br /> Standards and Specifications currently in effect, and to pay to the City its actu cost for removal and proper replacement of any item which <br /> does not meet the above requirements. Failure to comply will be cause for revc cation of this permit.Applicant agrees to indemnify and hold <br /> the City harmless against any and all losses, costs, or damages resulting from njury 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 perms:.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)937-8381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PJERMIT BE RE SIGNING'. <br /> Signed: G/��`T/v�- Phone: <br />