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MSPUBLIC WORKS DEPARTMENT 66506. r <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY 3k- 024 11 w <br /> Applicants Name Ad ImirtcA Geo EnyirornrtrAta a 8-17-0 Z APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (9vmer/Contractor) Subject to the General Provisions and Special Conditions, and all <br /> Address 831 561 R.1 � A Phone /� �QkJio work must conform to the projects approved Storm Water Pollution <br /> City S+& 0IC+0s4% State lit Zip 912 k5' Prevention Plan or the City of Stockton Storm Water Pollution <br /> p 1 Sck,�l'1, ceyl 1 er S-t Prevention Maintenance Staff Guide, whichever Is applicable. <br /> Location of Proposed Work, etc. ,,`` t <br /> Owner/ 8errtneteFAddress y 6 AAmi r` l Ik , s4cGL,44ovi B /? <br /> Date e <br /> Estimating Starting Date a at l '0 Completion Date 9' 3' % Z Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: l n54a Men ,'°ror "15 <br /> RLe Per 4a A fkd J Ce ( t R k% <br /> The above named applicant hereby requests permission to - (y A /tea <br /> _�jL�� AA ���' i` Q {{�� p1 PERMIT FEE ............... ....... ...... $ a li V <br /> 1`CYc t— +0 rt 771t� '-J L�: 11v F-- f I q. If <br /> Additional Footage Fee .."........ $ <br /> — <br /> 02 - Z I "� Trench Fee ...1.1........................1 $ <br /> ��XiCJ 4 Sewer Tap Deposit,...I... ..... ..... $ <br /> P�w TOTAL DEPOSIT ......... $ ✓ <br /> l <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> alvY aA'l./ <br /> Show sketch above or relay to drawing submitted At <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 does <br /> not meet the above requirements. Failure to comply will be cause for revocation of permit. Applicant agrees to indemnify 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 /> 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 <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE 2Efflj§JTJ=T BEFORE SIGNING, <br /> r ry <br /> Signed: Phone: a0 & 7" f VV6 <br /> 1st-Permittee (white) nd-Inspectlon (pink) 3rd-Flle (yellow) 4th-Finance (while) <br />