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CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT 74457 <br /> MS APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name _J,�iroa �e'o ��""�Fz`a�4 �e.( Date 1a' ?-1 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor Sub ect to the General Provisions and S ecial Conditions, <br /> Address kxtuo kna �) Phone -20q._ EI G /t'0 I p <br /> and all work must conform to the project's approved Storm <br /> City State C�4--Zip C15-21,r- Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. t of the City of Stockton Storm Water Pollution Prevention <br /> P 'S .v n,n t'cspy Cl.,et,!-�ir Maintenance Staff Guide, whichever is applicable. <br /> 5J2Of J`R,ttfllS�G(JS <br /> Owner/Contractor Address '95 4A") (ID . s i"Cy",rt¢ �Iv J(�✓� �'��G[ Date <br /> Estimated Starting Date 64 Z& Completion Date i!V4 3,, Ze(5" Permit`Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: ll Ia�Y�c`4 i�1nyS- 3 �Ybcs/l6Acli <br /> O✓I i ��' 1 S ��Poj C C-c i �',�. G C�c <br /> C. C110U . t ( 4p � V <br /> e , vV'Lc,, y <br /> ATTENTION: Applicant/Contractor—you are responsible to 22 <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ <br /> gutter from score mark to score mark adjacent to the parcel; 7 �—Z,tt <br /> remove USA markings upon completion of the permitted work. 4ddi e Fee .......... $ <br /> The above named applicant hereby requests permission to: L� 4�-� <br /> ��W9r <br /> TaprlPnnS $ A/11 <br /> --r- .................. <br /> st: B � TOTAL DEPOSIT ...... $ t. . <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> CONTROL WOOD- <br /> CALL (209) 937-M TO R-a0UF.ST A 'GONTROL <br /> NUMBr%--: NO LLSJ '1144,124 " URS, BUT ()T It, <br /> EXCESS OF 72k URS I�jUTk,TO STA'R 1`OF WORK <br /> v7,� <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 <br /> does not meet the above requirements. Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnity 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 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 <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 /> Sign Phone: <br /> 1s' -Permittee (white) 2nd -Inspection (pink) 3r11 -File (yellow) 411 -Finance (white) <br />