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CITY OF STOCKTON 66846 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> wnerlContractor)licant's Name ��o.e -re T4F, <br /> ( l� 1-112 <br /> `0Z APPROVED. BY THE PUBLIC WORKS DIRECTOR <br /> Subject to the General Provisions and Special Conditions,and all <br /> Address Z acs Phone YOc� wotk must conform to the projects approved Storm Water Pollution <br /> City State"f2L Zip s73-6-7.0 Prevention Plan or the City of Stockton Storm Water Pollution <br /> Prevention Marnie ce Staff Guide,whichever is applicable <br /> Location of Proposed Work,etc G rs�'G __•�T _ '¢" _. <br /> ,c K <br /> Owner/Contractor Address By TLIDate <br /> Estimating Starting Date /� G / 2a_ZComplebon Date 7-Ai'Q rmit Expi tton Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work KYAorn G <br /> The above named applicant hereby requests permission to <br /> PERMIT FEE $ <br /> �if7/J Additional Footage Fee $ <br /> T Trench Fee $ <br /> Sewer Tap Deposit $ <br /> TOTAL DEPOSIT $ <br /> Budding Permit No <br /> Improvement Plan No <br /> up lemental Conditions (�� <br /> i� @2 e�iV t,�l�tlYl$Q�',r'6 jam' <br /> 2) U)or� �c,krs at l <br /> � `t s� WA* 6p, Clear <br /> Show sketch above or refer to drawing submitted Q afA <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 cosi for removal and proper replacement of any Item which does <br /> not meet the above requirements Failure to comply will be cause for revocation of permit Applicant agrees to indemnity and hold the City <br /> harmless against any and all losses,costs,or damages resulting from injury to persons,death of person or damage to property occurring at the site <br /> of,or as a result of,work to be performed under this permit A certificate of insurance shall be submitted to the City Risk Manager prior to Issuance <br /> of this permit. <br /> PERMITTEE SHALL CALL(209)937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> FDIIMV <br /> E INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER (FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> ISIONIMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR <br /> FIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERM ORE SIGNING <br /> Sign / <br /> 1st-Permittee(white) 2nd-Inspectkut(pink) 3rd-File(yellow) 4th-Finance(white) <br />