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1 ppq <br /> CITY OF STOCKTON r7 1 <br /> PUBLIC WORKS DEPARTMENT J i 1 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> l <br /> Applicant's NamePDVMLC90 CCEDWlf2o ✓M60AIDate Z767- 70W APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> {AwrtedCopntra�c9lor) <br /> D 3 / S� Phon� , �yd Subject to the General Provisions and Special Conditions, and all <br /> Address 201 7—�bOFi work must conform to the project's approved Storm Water Pollution <br /> city State —CA— ZIP 9,S 2�� Prevention Plan or the City of Stockton Storm Water Pollution <br /> ST Prevention Maintenance tall Guide, whichever is applicable. <br /> w ( <br /> Location of Proposed Work, etc. so e7C� <br /> DC oA1LJ �2n���t\�`S lLPcf� vn et <br /> Owner/ EentreeMrAddress lbi S- L'�.A��l,(L ST 5�rit&Zr� M By Date �v <br /> Estimating Starting Date 0'7 � 36 " U ( Completion Date f t - D ' 0 ( P it Expiration Date -t <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: ADVAALLjEw y x251. L <br /> hteikt(� WFIL ( 74 / A .'`Pu< 0 - �vz�iTCPT E& re gffW 17s FT BEW <br /> 45 <br /> la+l P-Will 1P Ak <br /> Saa4 04 <br /> p 1e cL <br /> D v 7E/ V LL r4 TkZ 5AII�PLEq Agi r6LI.CC7iCD , ,t(, <br /> MILL RE cDacpF E�IACLrlLuAlk btl � T/ laPAiT PbVrcAx1T> r <br /> IS AA ( I-(Cjlk7 EA c'o EIL LL4-, P( ET V (AJ 5 lj�AS <br /> The above named applicant hereby requests permission to <br /> n . / CLQ, �� dd nn ,r f PERMIT FEE .......... .................. $ �f <br /> F.E ee TO ESL CLOSED KAV I F wajzk 2 Additional Footage Fee ........ .... $ <br /> Trench Fee ..1.111 ,1.. .............. . .. ... $ <br /> Sewer Tap Deposit.................. .. $ <br /> TOTAL DEPOSIT " ,..... . $ // <br /> 00 <br /> Building Permit No, <br /> Improvement Plan No, <br /> Supplemental Conditions: <br /> " <br /> I (��riHt�j a�\A_SsW rJC, , bttiy�T�r�.f �C�let.tli?4M1t, <br /> 0-1, ev a�vta �p" PCZ <br /> Show sketch above or rater 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 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 NPMBER WILL <br /> BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER. (FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS, PERMITTEE SHALL CONT TTHEASSIGNED PfY PROJECT ENGINEER AT (209) 937-8411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNV WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SI E OF THIS <br /> Signed: - Phone: <br /> 1st-Permittee (white) 2nd-Inspection (pink) 3rd-File (yellow) 4th-Finance (white) <br />