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OCKTON <br /> CITY OF STDEPART 7 1908 9 0 8 <br /> aele" <br /> PUBLIC WORKS DEPARTMENT <br /> M05APPLICATION FOR E11 NCLLROACHMENT ON PUBLIC RIGHT-OF-WAY /- rtOg,Ua UJ <br /> Applicant' e �GO(M0.�17>( Lo1hWBat� 2�F$ APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner Contracto 1 Subject to the General Provisions and Special Conditions, <br /> Address 128( E,/[Ilu Vtal Av--, "Nhone and all work must conform to the project's approved Storm <br /> City FrLSKo State G—Zip Water Pollution Prevention Plan or the most current version <br /> of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work,etc. IR 13 INA r71Nfa�1r3� pf Maintenance Staff Guide,whichever is applicable. <br /> ---�— t ��- CSC/� � L �� � � <br /> ` —� l >(� <br /> Owner ontractor ddress SAS– Ah iA.boVC By Date <br /> Estimated Starting Date Jt.1A - S Completion Date �� Permit Expiration Date /I✓>> <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: �N 4 uutk*_ <br /> WCA I t ,c �- h4w, + e[ bo - - w <br /> ri )pk t.-e. e 5 11e-uf <br /> wa I l ` It'N. Gilt 1' <br /> J 4eww[.K <br /> ATTENTION:Applicant/Contractor-you are responsible to <br /> replace all broken,damaged, and/or raised sidewalk,curb and PERMIT FEE........................... $ 00 <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 ts: <br /> Sewer Tap Deposit.................. $ <br /> 4Pe <br /> OTAL DEPOS ...... $le OSrBail� rmit N DC <br /> Improvement Pla No. <br /> Supplemental Con itions: <br /> PERMIT NOT VALID WITHOUT A <br /> CONTROL NUMBER, <br /> CALL (209) 937-8366 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, OUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> Shaw sketch above crisis,to drawing submitted CON•T'`OL#-------_._ <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 indemnify and hold <br /> the City harmless against any and all losses,costs,or damages resulting from injury 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 SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(2D9)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 /> 6-0 <br /> v"aSigned: Phone Z(�/'253� <br /> 1"-Permittee(white) tad-Inspection(pink) 310-File(yellow) 41h-Finance(while) <br />