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CITY OF STOCKTON 72437 2 7 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Flame �r1rrN7�l �ry4iN�E+�d.�+l~ Date �'1`�� APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> Address Phone /L6' _? Subject to the General Provisions and Special Conditions, <br /> q �,,� and all work must conform to the project's approved Storm <br /> City AbTr,ELLyo F_ State Zip qO y3 Water Pollution Prevention Plan or the most current version <br /> p / �1fz N�� c� of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. / F Maintenance Staff Guide, whichever is applicable. <br /> Iti! <br /> CALtF E , pr ti 3Z 'casr ©iF 'L'A- Z)r <br /> - ,�%�� <br /> Owner/Contractor Address 54 AAE By Date <br /> Estimated Starting Date —7d ( Y r0'9' Completion Date O g Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> t4�w C)VZ<Sv N47 e?Z- /t44"v 1- -044 IN 4, five 1 L M Gt/ - /�s --n— u <br /> C <br /> .5;/ -/-C Z3/s- N. GSI c r 2�v �–i-, 455 <br /> Pir <br /> /1/ / <br /> ATTENTION: Applicant/Contractor-you are responsible to z 4 <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 named applicant hereby requests permission to - <br /> -TrZIA Fr-it: ri pLISewer Tap Deposit.................. $ <br /> ,'Z31 5 N • — (A/.��tf _G rf . <br /> �/VE � TOTAL DEPOSIT ...... $ <br /> ALI�eN/A <br /> STPD T I I i4w4diag-Rermit No. ��G-✓ <br /> X7, Improvement Plan No. <br /> I i <br /> ��-+ 44� Supplemental Conditions: <br /> t <br /> OIL <br /> CALL (20q` P37-e"sP37-8366 TO REQUEST <br /> �7-T r1l��i:!BC`R NO I-ESS VkN 24 HOUR <br /> `:CESS <br /> OF 7[2f HOURS PRIOR W START n1 <br /> Show sketch alSove nr 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.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 T14E 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 /> I'�-Permittee (while) 21c' -lnsrmction {Mink) 3111 F Ile fvnllnwl 4111 -Finzinrr, twhdra) <br />