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CITY OF STOCKTON � � v � <br /> 'PUBLIC WORKS DEPARTMENT <br /> 74 <br /> APPLICATION FOR ENCROACHMENT. ON PUBLIC RIGHT-OF-.Wil <br /> Applicant's C��;1Ur j'Cr�.i • I,rC�`1fli'C�S D - <br /> A <br /> pF ate APPROVED: BY THF PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor). <br /> Address _ \\Q _��� SN_e.CA_ Phone[24SZZ- Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City E4 �c .e �:� State (_R Zip �f�J`��� Water•Pollution Prevention Pian or the most current version <br /> Location of Proposed Work, etc. of the City of Stockton Storm Water Pollution Prevention <br /> p } i �r� ~r--_� J MainjtwTnce Staff Guide, whi ever is applicable. <br /> Owner/G6;t_r_ r Address to?-)! [L'S' C. (-,w?J Ro.I x By- � Date <br /> Estimated Starting Date 1— 2,00 Completion Date •tel-k' Permit.Expi ration Date.__ ~/-.Q <br /> I (or We)hereby apply for an Encroachhtme``nt Permit t4b carry"the following <br /> "work: �4°(l_�'1(:11n�1 �1�L7 ��•�.`��1C`,�j <br /> J <br /> - <br /> ATTENTION:Applicant/Contractor-you are responsible to 4 <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; <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 /> �'-Cr_C�'1 e� <br /> JCc �— <br /> TOTAL DEPOSIT ...... $ � <br /> --(� Building Permit No. <br /> Gw.ou -maj 1echn�c Improvement Plan No. <br /> Supplemental Conditions: <br /> 1�7 . A <br /> PERWT NOT VkUD WITHOUT A <br /> CONTROL NUMBER. <br /> CALL,(209 937-8366 TO REQUEST A CONTROL <br /> NUMBER No LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR,TO START Of WORD <br /> Show sketch above or refer to drawing submitted „e <br /> ONTROU <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 perdons, 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 CityRisk <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 /> Signed: Phone: - 7f',f <br /> 15'-Permittee (white) 2nd-inspection (pink) 3111-File (yellow) 41n -Finance(white) <br />