Laserfiche WebLink
CITY OF STOCKTON QO P"OW <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT <br /> MENT ON PUBLIC 70035 <br /> Applicant's Nam ET— ,, tl,�G Iti '� � Date <br /> (Owner/ ontracto -- APPROVED: BY THE PUBLIC WORKS DIRECTOF <br /> Address Lam' 1� . 1 i�� V�(,I'�v Phone 2-s- 1�j Subject <br /> _ � ��[Q j t to the General Provisions and Special Conditions, <br /> City t ., and all work must conform to the project's approved Storrr <br /> �t-Lr. State � ' �-�'a'�i,- <br /> Zip <br /> _ Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work; etc. of the City of Stockton Storm Water Pollution Prevention <br /> AMaintenStaff Guide, whiche is applicable. <br /> Owner/Contractor AddressByDate <br /> Estimated Starting Date 0 Completion Date 21 /zu�? it Expiration Date <br /> I (or We hereby apply for an Encroachment Permit to carry out the following work: In <br /> I­ <br /> CAR, <br /> �lh✓ <br /> tA <br /> tJ i_ <br /> ATTENTION:Applicant/Contractor-you are responsible to <br /> replace all broken, damaged, and/or raised sidewalk, curb and <br /> gutter from score mark to score mark adjacent to the parcel; PERMIT FEE........................... $ <br /> i <br /> ,remove USA markings upon completion of the permitted work. ft <br /> Additional Footage Fee.......... $ � <br /> The above named applicant hereby requests permission to <br /> r Sewer Tap Deposit.................. <br /> ,'_)EE HWE, 2- CAI,T .,L EU $ <br /> TOTAL DEPOSIT ...... $ --32 <br /> ('Q <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> i <br /> <ARMT NOT VAU W17HOUT A <br /> rC 'gyp, -C',ONTROL NU�a8ER <br /> (2019) 9374365 TO REQUEST A CONTROL <br /> -RIZb L �C C -'"C-TIMBER NO LESS i HAN 24 HOURS, BUT NOT IN <br /> r XCESS OF 7?POURS PRiOf1^ TO START OF V}1CtRK <br /> Show sketch above or refer to drawing submitted D <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 <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 ANEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 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(209)937-8381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> J�✓�/�i/i s< ]� <br /> Signed: � „� I � Phone: <br /> X51 Permittee (white) 2"d-Inspection (pink) 31d-File (yellow) 41h-Finanrc f,nrhitol <br />