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CITY OF STOCKTON 71033 PUBLIC WORKS DEPARTMENT 4 mw AN APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY Applicant's Name RtAmi!n tCA b,P-LnV jrwI M{ .Dae 5-3- 0 APPROVED: BY THE PUBLIC WORKS DIRECTOR (Owner/Contractor) lj i Address $ Sh"V f�CA. Phone q0 r1(90� Subject to the General Provisions and Special Conditions, and all workrmust conform to the project's approved Storm City !94yc k cn State GA Zip S Z 15 Water Pollution Prevention Plan or the most current version of the City of Stockton Storm Water Pollution Prevention Location of Proposed Work, etc. irl ti`k. 0f N-fmc.i• 01211 Maint1ena Staff Guide, which er is applicable. 4, V��00 i Gl CLI Y-G LP i a n ctiA �IY fJ rn! a.f ►K ByDate 5y 00 ierr Estimated Starting Date lro"15 '0 Completion Date -0 77 Permit Expiration Date '/jCJ I (or We) hereby apply for an Encroachment Permit to carry out the following work, Ha YA i n!j we -41 _ r f dyc:r<e&mQ.#d of- Z s,j 6c+►ir►4c 4v amoroxi rl Ir-1 -eci5�., of ,] t ru bg co i,no(a-1+-e -Sa w,R Ir s i nCx n aI s f-_o of e c,r 4 tc t S t fest_e n `flt-c_ -vid tw t I k s;41-C cn fA 1,/4 V ct j(ess ' `f 7t. _ 2-fre to (f4dvrLny Villa A. ATTENTION:Applicant/Contractor–you are responsible to replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ � gutter from score mark to score mark adjacent to the parcel; ;f remove USA markings upon completion of the permitted work. Additional Footage Fee .......... $ The above named applicant hereby requests permission to: P I Sewer Ta Deposit.................. $ 'i �. et f SP t7LG TOTAL DEPOSIT ...... $ -331 D e I !Yl Building Permit No. Improvement Plan No. Ii Supplemental Conditions: -OUT A PERMIT NOTVALID 47 CALL (209) 93+ "�9 TO RE�iLE I --; CONTROL NUMBER �O LESS, TWA2 i-iOUIRS, BUT NOT IN EXCES�OF 72 I-O IRS PRI R T"5 �R r t '1�rj K, Show sketch above or refer to drawing submitted IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit, as well as all applicable city ordinances, resolutions, 1 Standards and Specifications currently in effect, and to pay to the City its actual cost for removal and proper replacement of any item which does not meet the above requirements. Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnity and hold the City harmless against any and all losses, costs, or damages resulting from injury to person's, death of person or damage to property 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 Manager prior to issuance of this permit. f Ii I IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CIN PROJECT ENGINEER AT(209)937-8411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE.BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937-8381. ?w . READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. Signed: j Phone: L44q -10Q(o S' 151-Permittee (white) 2nd -Inspection (pink) 3111 -File ('ellow) 41h -Finance (white)