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04/16/2001 07:22 2094671.: AGE STOCKTON PAGE 04 <br /> F <br /> CITY OF STOCKTON 7 i <br /> PUBLIC WORKS DEPARTMENT <br /> M9 M5APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT OF•WAY ��M,6045�/ <br /> Applicant's Name Date APPROVED: BY THE PUBLIC WORKS DIREECTOR <br /> {Owner/Contractor) <br /> Subject t0 the General Provl6lans and Specie)Conditions,and all <br /> Addresb Phone work must conform to the project's approved Storm Water Pollution <br /> City State Zip Prevention flan or the City of Stockton Storm Water Pollution <br /> Prevention Maintenance la Gui e,whichever is applicable. r <br /> Location of Proposed Work,etc- <br /> I <br /> owner/Comracto ddressBy Date <br /> Estimating Starting Date ! ' Completion Date It Expiration Date <br /> J (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> The above named applicant heraby rvquQ$%pam+issi4n=o• J, / I' <br /> PERMIT FIE............................$ <br /> J Additional Footage Fee..-.....---.$ <br /> Trench Fee............................... $ <br /> Sewer Tap Deposit.........:.........$ <br /> l <br /> TOTAL DEPOSIT.........$ I <br /> Building Permit No. <br /> Improvement Pian No. ___..._. <br /> Supplemental Conditions: <br /> CI�d d lW 8 I�C <br /> l <br /> SNOW ekAkh AlSpvg or Mer16 tlr&WiAA Submitted - <br /> t <br /> IMPORTANT: Applicant hereby Agrees to Comply"with all provisions of this permit,as well as al applicable City ordinances,resolutions, <br /> Standards and Specifications currenify in effect,and to pay to the City lts actual cost for removal and proper replaeernont of any Item whloh does <br /> not meet the above requirements.Failure to Comply w11I 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 SRO <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 f <br /> of this permit. f� <br /> PERMITTEE SHALL CALL(208)937 6 FORA 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 REOUIRED INSPECTIONS.AS IDENTIFIED ON THE REVERSE SLOE 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 NUM6ER.(FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACTTHE ASSIGNED CITY PROJECT ENGINEER AT(tog)837-6411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERMIT PEFORE SIGNING,Sig ned�. VIJIJSJ�+"� } ...__..- Ph4n8: <br /> tst-Pefmittee(wnge) 2nd-Inspection(pink) 3rd-File(yellow) 4th-Finance(whits) <br />