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C), <br /> CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT 7 4 1 3 7 <br /> E- APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> r ikpplicant's Name_ � � Date in APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> + (Owner/Contractor) Subject to the General Provisions and Special Conditions, <br /> Address 41 5D Phone and all work must conform to the project's approved Storm <br /> City R!L_� State C_zip_JsLj?�p Water Pollution Prevention Pian or the most current version <br /> of the City of Stockton Storm Water Pollution Prevention <br /> t <br /> Location of Proposed Work,etc. Sl0fMiALy-- Ong lhr l S►flr, Maintenance Staff Guide,whichever is applicable. <br /> OE M DP!LAb_0_�g Soin M bf-' L6 AN LT:z �9 NW41i <br /> Owner/Contractor Address %nArk AS A bib* ByDate( <br /> Estimated Starting Date f Uilp Completion Date Permit Expiration Date / �� <br /> I <br /> 1"r IJA41 <br /> i <br /> I(or We)hereby apply for an Encroachment Permit to carry out the following work: b9grr2=W Our! 140o rra'L�G„_,—_ tA�)_�—I__1 <br /> .� <br /> 'f 5sT 1nl1u. R9EYi ] -R� IC� �.1rN�'7fsD {°p` S I�A� . S1rF�_ <br /> e <br /> R ; ATTENTION:Applicant/Contractor—you are responsible to ❑ <br /> replace all broken,damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ 5�2. P-1 e <br /> gutter from score mark to score mark adjacent to the parcel; c <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $ <br /> The above named applicant tweby requests permission to <br /> Sewer Tap Deposit.................. $ <br /> TOTAL DEPOSIT ...... $ <br /> AWA cA et) S 1vf—, Vk A Q Building Permit No. <br /> FImprovement Plan No. <br /> Supplemental Conditions: r <br /> PERMIT NOT VAUD WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 9374366 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BIIT-NOT IN <br /> { EXCESS OF 72 HOURS PRIOR M STAWOFMW <br /> Shaw sketch above or refer to drawing submitted <br /> CONTROL# <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 cast 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)937-9411 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 VW)8374381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> IL <br /> Signed: Phone: Q��Q•q • <br /> WIG <br /> F 1st_0IIrmitf44 1—hital ond Jncnanti.+n lr,i.,4\ 7rtl CPt_ /....u.,...t <br />