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PUBLIC WORKS DEPARTMENT 7 12 G <br /> -zS APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> AApppi gags Name �✓ ate 3 ! APPROVED. BY THE PUBLIC WORKS DIRECTOR <br /> (bwnerlGontractor) <br /> Subject to the General Provisions and Special Conditions,and all <br /> Address t V Phon(V 5(b-'130 work must conform to the project's approved Storm Water Pollution <br /> City G State (A Zap 1%.3Y Prevention Plan or the City of Stockton Storm Water Pollution <br /> WAY, Maintenance Staff Guide,whichever Is applicable <br /> Location of Proposed Work,etc �5 wE G <br /> t 3 <br /> OwnerlContractor Address By Date <br /> Estin-"ng Starting Data a Completion Date ermit Expiration Date l] <br /> (or We) hereby apply for an Encroachment Permit to carry out the following work Sr .�4-r1a OIC <br /> 3 �l r7�v o .re I�v�ZL fli✓ OIL/ L G c✓ <br /> hby- w•v� o <br /> 1 The above <br /> �named <br /> lapocant hereby requests permission to- C7 <br /> 1/IY7'� 5L/$/y� PERMIT FEE $ <br /> Additional Footage Fee $! pl <br /> Trench Fee $ rep 0 3 — Oct.,-, <br /> Sewer Tap Deposit $ <br />' TOTAL DEPOSIT $ <br /> Building Permit No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> See 1*4 77� <br /> Show sketch above or refer 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 NUMBER WILL <br /> BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER (FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS, PERMITTEE SHALT_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 OF THIS PERMIT 13EFORE SIGNING '' C J (� <br /> Signed _ Phone I qW 5b5- 135-3 <br />