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CITY OF STOCKTON 70384 <br /> PUBLIC WORKS DEPARTMENT _ <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Nam p t NC Date � APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor Subject to the General Provisions and Special Conditions, <br /> Address ,� Al Phone 2-3!4 <br /> —a _ and all work must conform to the project's approved Storm <br /> City 10 c. _nAo State (�A Zip !1!5 Water Pollution Prev ntion Plan or the most current version <br /> of the City of Stock 3n Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. PACK),UG A V(_- l)C--S-r 5-1 b S Mainte nce tall uide,whichever is applicable. <br /> Owner/ContractorAddress zu By c Date Oy <br /> Estimated Starling Date5EIV <br /> b"i=7, 7106 Completion Date 5�7;b, Zd��,_ Permit Expiration Date <br /> I (or We) hereby <br /> apply for an Encroachment Permit to carry out the following work: 3 1�i✓L"i' r4 <br /> r- /1_r A 1 EZ&z:c- i s P&-� ,F_-;4 b._ S�tSEr r- 'r-inxi /4s t- <br /> Gi <br /> T-!:!(/� 3L_JC _ Ltd C5) rn�- <T-1 if>C 4,76 A) ! iZOA25 <br /> I <br /> ATTENTION:Applicant/Contractor—you are responsible to <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ '3 31 -06 <br /> gutter from score mark to score mark adjacent to the parcel; <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee .......... $ <br /> The above named applicant hereby requests permission to <br /> Sewer Tap Deposit.................. $ <br /> TOTAL DEPOSIT ...... $ O Q ! <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditio!n�s: <br /> s�-L. f3E LtMc7-60 —1 1 �1� <br /> PERMIT NOT VAUD MHOUT A � <br /> MW"MOL NUMBER. <br /> CALL ,�t12;X37, ' TO REQUEST A CONTROL ' <br /> NLl?fBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> Show sketch shove or refer to drawing submitted CDWRIrGL�-,-- <br /> IMPORTANT. <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. I� <br /> IF THE WORK.DOES_NO:LCOMMENCE WITHIN 72_HOURS OF_THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL 1 <br /> BECOME INVALID AND THE PERMITTEE SHALL GALL--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 SPECIFIC i <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE i <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 /> r <br /> Signe-,A'."" Phone� �z3�ds�� <br /> GG—u- 961--20 3 <br /> is1-Permittee (white) 2nd-Inspection (pink) 3,d-File (yellow) 4th-Finance (white) <br />