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CITY OF STOCKTON <br /> -PUBL-!C`WORIES DEPARTMENT . 77187 <br /> GAPPLICCATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> ` <br /> Applicant's Name / ! DateCIP <br /> 1 I`r APPROVED: BY THE-PUBLIC-WORKS DIRECTOR <br /> (Owner/Contractor) S}>, �0�r S 79- Subject to the General Provisions and Special Conditions, <br /> Address gut V(a Pi e—on �, -Fi -Phone -,99 <br /> and all work must conform to the project's approved Storm <br /> City d^VGt.--iJ State C-6- Zip 9 l�L Water Pollution Prevention Plan or the most current version <br /> of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. S 4 f r1 Maintenance Staff Guide,whichever is applicable. <br /> tf Ci✓-t OA S L-0 C K I o S' (,-T C,? A.+,xo) <br /> Owner/Contractor Address C 1_�e.-_.11 SMC By W It- "t(i W b(" Date "(- <br /> Estimated Starting Date T y Completion Date -7f jt� / �/ Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: '-A a") �� ,5 r 11 <br /> ATTENTION:Applicant/Contractor-you are responsible to <br /> replace all broken.damaged, and/or raised sidewalk,curb and PERMIT FEE........................... $ �� �V <br /> gutter from score mark to score mark adjacent to the parcel; <br /> remove USA markings upon completion of the permitted work. Additional_F otage-Fee.--�q(/.1.�/ $ '35 13 <br /> Tho.above named applicant hereby requests permission to <br /> S�,.w,er-Tap-Deposit......... $ 1� �rQ <br /> TOTAL.DEPOSIT ...... $ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> REM 17 NO 01 XrkAG W- 11(rWIPEJ'<<A, <br /> CP�I� SS C (3u r Zvq-R31— N9374= <br /> LESS x -Waft, ��WA N <br /> -11) t!3 fon- v wAT It t► �',"1lu-I MESS(Y 72 HOMr To sIART CIF V'X.frK <br /> KIMCI <br /> Show sketch above or 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 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 PERMIT BEFORE SIGNING. <br /> Signed: �� Phone: 3 qs(o <br /> CTI <br /> 157-Permittee(white) 2nd-Inspection(pink) 3rd-File(yellow) 4171-Finance(white) <br />