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11/08/2652 11:27 2094671" " '3 AGE STOCKTON PAGE B2 j CITY OPSTOCKTON 67572 PUBLIC WORKS DEPARTMENT APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY 6�eoo.3/FV-7— Appticant's Name ate�� APPROVED- BY THE PUBLIC WORKS DIRECTOR (OwnerlConiractor) l 1 moi? jp��r Subject to the General Provisions and Special Conditions,and all Address . V _ Pho�e/� Kf work must conform to the projects approved Storm WaterPollution City !f State zip "t Prevention Plan or the City of Stockton Storm Water Pollution 3 Prevention Maintenance Staff Guide,whichever is applicable. Location of Proposed Work,etc. J Ir r f Owner/Contractor Address t` 7 =& By _ _ Data r Estimating Starting Data 11-10--2, Completion Date Permit Expiration Date �- I (or We) hereby apply for an Encroachment Permit to carry out the following work: f l 4k Gk t - -� the above named applicant haroay requests pormission to• . PERMIT FE=E............................$ Additional Footage Fee........-.. $ � Trench Fee............................... $ Sewer Tap Deposit_.................. $ TOTAL DEPOSIT.........$ Building Permit No- Improvement Plan.No. Supplemental Conditions: y Snow eKelon above or refer to drawing submitted IMPORTANT: Applicant hereby agrees to comply with all prgvisiOns Af thig permit,as well as all applicable City ordinances,resolutions, Standards and Specifications currently In effect,and to pay to the City Its actual cost for removal and proper replacament of any item whiCh doe9 not meet the above requirements.f=ailure to comply wifl be cause for revocation of permit.Applicant agrees to indemnify and hold the City harmless against any and all losses,costs,or damages resulting from injury to persons,death of person or damage to property occurring at the site ot,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 of this permit. PERMITTEE SHALL CALL(209)937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT. IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILI- BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL,IMPROVEMENT PROJECTS on SUBDIVISION IMPROVEMENTS,PRRMITTEE SHALL CONTACTTHE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE B>=GINNLNG OF ANY WOAK.) READ GENERAL PROVISIONS ON REVERSE SIDE OF T S PEA IT FORE SIGNING. L'#frlfln/r/7 //f Signed;� 1St-Perrnitlee(White) -2no-InSpeClion(pink) 3rd-File(yellow) 41h-f9nance(white) 4 r