Laserfiche WebLink
6i�ql-sw oo5523�- <br /> CITY OF STOCKTON -00, 72612 <br /> "ro'PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC DIGHT-OF-WAY <br /> Applicant's Namev�.k� C�-_ Date � � APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner) ntrac S "/c 3(i,: Subject to the General Provisions and Special Conditions, <br /> Address i -1:; /i` ! Phone <br /> yr`— and all work must conform to the project's approved Storm <br /> CityState / 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. j11 t r f t, W-L (�)rLla W esi- Mainteraa ce Staff Guide,whi ever is applicable. <br /> '=r. �t t © Y 1u FIs " <br /> ntractor Address _ By '�,J/��'r'.r, ` ( Date <br /> Owner/Co } —v >- <br /> Estimated Starting Date q Completion Date Gr�_ Permit Expiration Date <br /> / ^ ` <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: r /7 4—C I-F: C <br /> S;r r t/ c c I ►'t Lt"1.� 9�� c2 1j•r /7 ( C Q .t 1 4l 2: X r ,,I_L tt c ' # c� <br /> ATTENTION:Applicant,'Contractor-you are responsible to <br /> replace all broken, damaged, and/or raised sidewalk,curb and PERMIT FEE........................... $ SOtom__ <br /> gutter from score mark to score mark adjacent to the parcel; <br /> rernove USA markings upon completion of the permitted work. Additional Footage Fee .......... $ _ <br /> The above namel apphcnni hereby requests permission to: �---- <br /> Sewer Tap Deposit............. .... $ <br /> TOTAL DEPOSIT ...... $ `O <br /> r pct , c rf 4 <br /> Building Permit No. <br /> j Improvement Pan No. <br /> r 1 Li- l yj/A Supplemental Conditions: <br /> . <br /> er i�ut.^i• �r`g ,?TJ V.ti�. "��-e-,'-" <br /> }r af_# (209) 937.01-4-31 O�},RECU,;:S�' ;', <br /> iYUttr,i"fS iVV LESS I�'u'S7Y 2lt ,�v f�7 v. su�T iN <br /> t:c, i% <br /> EXCESS OF 72 HOURS PRIOR Ti,STyRT CF i-VCr <br /> ,Show sketch above or€efet in drawing submitted <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit, as well as all applicable city ordinances, resoluticns, <br /> Standards and Specifications currently in effect, anc 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 njury to persons,death of person or damage to property <br /> occurrinq at the site of,cr 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(209)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 /> Signed. "' " tt <br />