Laserfiche WebLink
CITY OF STOCKTON <br /> PUBbCC,w6RKS=DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIG HT-OF-W <br /> M05CEID-:DEC1 2 � <br /> Applicant's Name- C�`I�L I 'TGC1')OVC-5 Date APPROVED: BYTHk PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor `ry <br /> Address k\ox ", '::" L Phone��SZZ-y1t"1 Subject to the General Provisions and Special Conditions, <br /> _ � 1 r and all work must conform to the project's approved Storm <br /> City_ � .E' Cg State Zip �7� `7 Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. of the City of'Stockton Storm Water.PdlliJt1dh Preventlon <br /> — ` y— Main nce Staff Guide,whi ever is applicable. <br /> ��.:. AA <br /> 6wner/dntract�r Address Cs5eX Ave (RouYvirlaIj By Date 4— <br /> Estimated Starting Date 2C ) Completion Date � � ' 0-) Permit Expiration Date <br /> (or.We) hereby apply,for an,Encroachment Permit to carry out.the:following.work: \,r '� . <br /> seg_ I -( m ems, 1 E51 <br /> ATTENTION:Applicant/Contractor—you are responsible to r <br /> replace all broken, damaged,'and/or raised sidewalk;curb and PERMIT FEE_ ........................... $ ' <br /> gutter from score mark to score mark adjacent to thio parcel; <br /> remove-USgmarkings upon completion of the permitted work. Additional,Footag e�Fee $ <br /> The above named ioptjcanl hereby requests permisslon fo �- <br /> Sewer Tap Deposit.... <br /> .............. $ <br /> TOTALIDE11069IT ...... <br /> Building Permit No: <br /> Improvement Plan No, <br /> Supplemental Conditions: <br /> CONTROL NU ER: . <br /> CALL-(249) 937-63I;6 TO RE-QUEST A CONTROL <br /> S, 6V NOT IN <br /> EXCESS OF 72 HOURSPRIOR To S <br /> IART N WORK. <br /> Show sketch above or refer to drawing'submitte-d <br /> — u�nnnnnw■i <br /> IMPORTANT: Applicant hereby agrees to c6mply with all provisions of this permit, as Well as all applicable city ordinances, resolutions, <br /> Standards and Specifications currently in effect, and'topay 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 injuryto per!ons,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 ACONTROL 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'CftY PROJECT ENGINEER AT(209)937-8411 FOR SPECIFIC <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)�PRIOWTO 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 /> Signed: Phone: <br /> ifif-ParmittpP (white) 2nd-Insnection (oink) 3rd-File(vellow) 01-Finance(white) <br />