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CITY OF STOCKY N <br /> tLJ(Ly� UBLIC WORKS DEPARTMENT 71448 <br /> Gfld�; APPLICATION OR ENCROACHMENT O PUBLIC RIGHT-OF-WAY <br /> Applicant's ame Date APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) Subject to the General Provisions and Special Conditions, <br /> Address r09�I �. 1�i� __ Irni 3nrr�o�nT_ Phone and all work must conform to the project's approved Storm <br /> City C,(,j';if_4*4 State C Zip Water Pollution Prevention Plan or the most current version <br /> of the City of Stockton Storm Water Pollution Prevention <br /> Location <br /> �(offProposed Work, etc. 131,5 1�;- C4x&,rky U14 Maintenance Staff Guide, whichever is applicable. <br /> Owner/Contractor Address A-e,,(n Ely Date4 - <br /> Estimated Starting Date — f 7_©� Completion Date Permit Expiration Date <br /> 1 (or We) hereby apply for an Encroachment Permit to carry out the following work: 644 k•t11 vA e- ", -C- <br /> GG�1°7'� -f ►r�-c c"o� 1�o.T -F - <br /> Sr 4*_ t4/t fL6`r'� � ✓f ll �,s! ,� royprlvr.� '.� is 3 1r1 `�lnne_TPl ck4d *k �v+�I{ d 6 01 36rep{ <br /> Gia..,A-Sr ,A ccfl�ecA- aT so S. ,S iGb "471 Jae_ Go/f1es 4i A4— 0 <br /> u "1, e� ed� s � �,� �..'rr 1e. -t- e- 4.4d &4- IF 0,X41 4 <br /> A , <br /> ATTENTION:Applicant/Contractor—you are responsible to r <br /> replace all broken, damaged, and/or raised sidewalk, curb and PEF MIT FEE........................... ' $ <br /> 3317 <br /> gutter from score mark to score mark adjacent to the parcel; &— <br /> remove USA markings upon completion of the permitted work. Add tional Footage Fee.......... $ <br /> The above named applicant hereby requests permission to <br /> Se er Tap Deposit................... $ <br /> TOTAL DEPOSIT ...... $ <br /> Building Permit No, i <br /> Improvement Plan No. <br /> d S r i Supplemental Conditions: <br /> PERMIT NOT VALID WITHOUT A <br /> CONTROL NUMBER. <br /> ALL (209) 937-B366 TO REQUEST A CONTROL <br /> IS UMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> C� E XCESS OF 72 HOURS PRIOR TO START OF WORK. { <br /> ONTROL# S'S 2 <br /> 1 <br /> Show sketch above or reier to drawing submitted _ <br /> i <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 i ijury 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 SHALLCONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)9374411 FOR SPECIFIC <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY FIEGUI14ED INSPECTIONS,AS IDENTIFIED ON THE REVERSE f <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 /> Signe Phone: <br /> {� tr r I h. 333? <br /> 1st-Permittee (white) 21111 -inspection (pin Td-File (yellow) 411' -Finance(white) <br /> I <br />