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i A CITY OF STOCKTON PUBLIC WORKS DEPARTMENT 7 4 1 1 8 F APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY i Applicant's Name ARCAe2 Date APPROVED: BY THE PUBLIC WORKS DIRECTOR (Owner/Contractor) r �4�� Subject to the General Provisions and Special Conditions, Address IS CA 1g1I0) and all work must conform to the projects approved Storm City��jLStiYyI ___- State V[ Zip 95tp Water Pollution Prevention Pian or the most current version of the City of Stockton Storm Water Pollution Prevention Location of Proposed Work, etc. 151p LK Nay UgQgQ OF Mainten a Staff Guide,whiche er Is applicable. Fpp wf AI� p{,h ;fit EAsT 5 ED Ct^ /� D +ner on3 actor add es& A� s� ._ „ N_ 6y Date "' Estimated Starting Date 201 o Completion Date. --u1N %b I a Permit Expiration Date 21— I r i � I (or We) hereby apply for an Encroachment Permit to carry out the following work: MAMA ^[ U916% M T 14 E D SC,t P ign W eLt- - l p12£s ATTENTION:Applicant/Contractor-you are responsible to replace all broken,damaged,andlor raised sidewalk,curb and PERMIT FEE........................... $ gutter from score mark to score mark adjacent to the parcel; 3� �3 remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $ The above named applicant hereby requests permissioe to: Sewer Tap Deposit.................. $ Q,,0KW-) S1b eV4 ArVV-- WeSM SMD, OF TOTAL DEPOSIT ...... $ S7 6 L Building Permit No. �• ATVALAfb 5,4'(C— laLAO Improvement Plan No. W L'1..l fj MV4 -IomhDTi t MW-- y Supplemental Conditions: 5 Mw- S , My j-aD 4M j MW MWf~3 t tAW-4) MW- 117C> PERMIT NOT VALID WITHOUT A FMw- IBM I Ca D CONTROL NU R. CALL (209) 937-&W TO REQUEST A CONTROL NUMBER NO LESS THAN 24 HOURS, BUT PLOT IN M'9-I AW j Mhr- 2 ate EXCESS OF 72 HOURS PRIOR T STARTOFWORK. F At- t " CONTROL# Show aketch 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 actual 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 tosses,costs,or damages resulting from 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 permit.Acertificate 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 CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937.6411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE �I SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)9374=1. READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. tt`^^{ Signed: Phone: F1' is!_ParmittAo (whifn) ?nd_Inenartinn/nin4l Cilo Mh -C:.,.,.,..,.