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i . + � CITY OF STOC o0 n- ON � �`a ; PUBLIC WORKSDEP RTMENT 70 7 9 3 APPLICATION FOR ENCROACHMENT N PUBLIC RIGHT-OF-WAY V G4CY Date 1 17-07 APPROVED: BY THE PUBLIC WORKS DIRECTOR, Applicant's (Owne Contractor9/6 7ZF��g�( Subject to the General Provisions and Special Conditions, Address Pone and all work must conform to the project's approved Storm City ? CST State Cid Zip g Water Pollution Prevention Plan or the most current version of the City of Stockton Storm Water Pollution Prevention Location of Proposed Work, etc. Maintenance Staff Guide,whichever is applicable. 2 3og�.230 �tf' G G •�-� �7 v�7 Owner i ontractor Address ,qn N A14� By at L�`"�''' / a Permit Expiration Date "-"/�� Estimated Starting Date � Completion Date p :I Ei I (or We) hereby apply for an Encroachment Permit to carry out the following ork: Ok rapeLye_ G ATTENTION: Applicant/Contractor—you are responsible to r replace all broken, damaged, and/or raised sidewalk,curb and, PERMIT FEE........................... $ ✓! gutter from score mark to score mark adjacent to the parcel; removel USA markings upon completion of the permitted work. Additional Footage Fee .......... $ The above named applicant hereby requests permission to: A 5 war Tap DeptNo. 6' .. $ P+' � _ Z- R e Permit X �30� Improvement Pl Z3� v V p �� o P66 P4,I6S pplemental Conditions: . p � r w- snaua►v - Ale RMT NOT VALtp WITHOUT 1 CONTROL NUMER, SAI 5iIQ Gv LIC CALL (209) 93744 TO REQUEST A CONTROL NUMBER NO LESS THAN 24 HOURS, BUT NOT IN -XCXSS OF 72 HOURS PRIOR TO START OF WORK, .r.w �62�og Show sketch above or refer to drawing submitted 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 actu al 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 indemnify and hold the City harmless against any and all losses, costs, or damages resulting frorT 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 perrr it.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 CONTRO L NUMBER. (FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT 7-841 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. L s- Signed: Phone: is 151-Permittee (white) 2"d-Inspection (pink) 3111-File (yellow) 41h-Finance (white)