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CITY OF STOCKTON 75336 , <br /> DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name 54a.4",_ Date APPROVED: BY THE��RECTOR <br /> (Owner/Contractor) Subject to the General Provisions and Special Conditions, <br /> Address 3el x %cif r R4. .. 5�„Jt 1GY)___-_ Phone 9 tG-9b1•c'10C) __ and all work must conform to the project's approved Storm <br /> City State ('A Zip q5-6/0 Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. r ill ,, of the City of Stockton Storm Water Pollution Prevention <br /> . .r. q,,k �:.rk . nr W0 Maintenan a Staff Guide,which, er is applicable. <br /> A-u ;.e_ V,,4 0,i ,Lkcd S, ., 1'..) <br /> Owner/Contractor Address ,, By Date <br /> Estimated Starting Date ~_r` .- Completion[?ate Permit Expiration Date _ �.15 <br /> (or We) hereby apply for an Encroachment Permit to carry out the following work: Pfpc� r d<.Irr,A 4hr,.c q>avitcl, ,JQ . rte,Fob_ <br /> I) S A J C 4-0 1 rH 00k P rtr - i• .'� r �,Or 11.4 Cl' d V <br /> l "4 <br /> ATTENTION:Applicant/Contractor—you are responsible to S2-3 <br /> replace all broken,damaged, and/or raised sidewalk,curb and PERMIT FEE........................... $ <br /> gutter from score marts to score mark adjacent to the parcel; � 1_ <br /> remove USA markings upon completion of the permitted work. Atft l z" age a.......... $ <br /> The above named applicant horoby requests permission to: &/Z fj C <br /> Ste +tni .46cf S,4 Pl" t lk, %a. �a:. 1 .... �i hi..�it ad `7�TJC�Q .......... $ f f1 <br /> TOTAL DEPOSIT ...... $ 57,2.69 <br /> Building Permit No. <br /> Improvement Flan No. <br /> ku -1�4";%W I�. HOST A <br /> G TROLn I-�}UaryMSM TO REQUEST <br /> COMM <br /> Nijki ER NO LESS THAN 24 HOURS, 8UT NOT IN <br /> EY,"ESS OF 72 HOURS PRK)R TO START OF A. <br /> CONIPOL9 <br /> Shaw sketch above at 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 indemnity 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.Acertificate 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)937-6381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Signed. g� r�L _ <br /> � Phone- <br /> :.I-rrnittee (white) i-)spectior(pink) 3' t .,(yellow) 41" -Finance <br />