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ENCROACHMENT PERMIT Permit Number <br /> cITYOF N° 77258 <br /> STOCKTON ON PUBLIC RIGHT-OF-WAY <br /> Applicant: Date: <br /> APPROVED:BY THE DEPARTMENT DIRECTOR <br /> o <br /> ubject to the General Provisions and Special Conditions,and all work mus <br /> Address: �j (, � G onform to the project's approved Storm Water Pollution Prevention Plan at <br /> H he most current version of the City of Stockton Storm Water <br /> Pollution Prevention Maintenance Staff Guide,whichever is applicable. <br /> City: _ _ ���""D� State: � ZIP: � � �� LL <br /> Y:411tL,t �/ til Date: i l i <br /> Phone: E-mail: <br /> ssociated Permit(s): Expiration: <br /> - i <br /> ORK OCATION: ��� N{N►'CN '„ ct�/ l�7tx/d�Al.� <br /> Start Date: ��r Completion Date: 'S��! '��� 5�: � InQ� <br /> *7 A6-@,4= c r R. <br /> ii."s', .i,;,i fi <br /> ATTENTION:Applicant/Contractor-you are responsible to replace all broken,damaged, CA) (T.y?`1 10,;IEQEST A =RM rn, ,*t <br /> �' ?t.t";c 'v S;2� 4fi.`x.jS2S, UT NOT ut. <br /> and/or raised sidewalk,curb and gutter from score mark to score mark adjacent to the Y1" ` <br /> parcel;remove USA markings upon completion of the permitted work. � J.� /l"0IJRS[5XXt TyOS IAM O t' <br /> I(or we)hereby apply for an Encroachment Permit to carry out the following work:4 <br /> • aloow t 6•.• ori , , o�,a � Y)Jd &Ajt&rad d.kcLi r,sr a• <br /> Show sketch or refer to attached Drawing 8 <br /> NOBase Permit Fee <br /> 4 Additional Footage Fee $ <br /> Misc. i� $ �• „Z3 <br /> Misc. {;�S $ <br /> s <br /> »� � Misc. is <br /> v ! Total $ 512-bC� <br /> Special Conditions: <br /> Ly ( COq-�SO V brt' L-- fkT <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit, as well as all applicable city ordinances, resolutions, Standards and <br /> 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 <br /> requirements. Failure to comply will be cause for revocation of this permit. Applicant agrees to indemnify and hold the City harmless against any and <br /> all losses, costs, or damages resulting from injury to persons,death of person or damage to property occurring at the site of, or as a result of, work to be <br /> performed under this permit.A certificate of insurance shall be on file with the City Risk Manager prior to issuance of this permit. <br /> IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE <br /> OF A CONTROL NUMBER, THE CONTROL NUMBER WILL BECOME INVALID <br /> AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER. PRIOR TO <br /> ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> Sign <br /> PERMIT,PERMITTEE SHALL CALL INSPECTIONS AT(209)937.8381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE <br /> SIGNING. Print e SSCWJ r <br />