Laserfiche WebLink
T` • • SRoo35Z `� <br /> i- <br /> CITY OF STOCKTON 6 7 7 18 <br /> PUBLIC WORKS DEPARTMENT <br /> MIAPPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name Con d or Ear r l eci \JccVate ! 1 0 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> Subject to the General Provisions and Special Conditions,and all <br /> Address 18 B Fra•,1< W-"rCr• .57-e,.I- PhonepZ0c`0I Z3 Y 0S/fi work must conform to the project's approved Storm Water Pollution <br /> City S'T�(T tAn Stale� Zip 2� Prevention Plan or the City of Stockton Storm Water Pollution <br /> ~y (� I Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc. Pl�rvoTq <br /> Cei <br /> 0 L4 - riy C I. I, ; C C 1.6 S f;g t2 300�asTa� ®lY. "�( <br /> �.. a l rl r 7,9.rn - o,. T 1, T'a a^ci <br /> Owner/Contractor Address yih�0— By A��—Da/t ? <br /> /z_0 <br /> Estimating Starting Date �� Completion Date //�-/.D'� Permit Expiration Date �J <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: Ci d"ncr <br /> — 1 6 rc n I <br /> an' L li-rab ro ✓ `�._d b� H tc�l1 <br /> Tra c 5 V-GL <br /> The above named applicant hereby requests permission to- ( <br /> r PERMIT FEE............................$ d <br /> hort •,5 wr ll <br /> Additional Footage Fee............ $ <br /> d ;ar>1c�tr o7 3 , <br /> Trench Fee............................... $ <br /> Sewer Tap Deposit.................... $ <br /> t <br /> TOTAL DEPOSIT.........$ <br /> Building Permit No. <br /> !!! / Improvement Plan No. <br /> Supplemental Conditions: <br /> Show sketch above or refer to drawing submitted <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 does <br /> not meet the above requirements.Failure to comply will be cause for revocation of permit.Applicant agrees to indemnity and hold the City <br /> 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 <br /> 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 <br /> of this permit. cj cr CC-�'rrpk <br /> PERMITTEE SHALL CALL(209 937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE START OF WOI� D PRIOR TO ANY REQUIRED INSPECTIONS,AS—I6�.NTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT.IF WORK DOES NOT BEGIN 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 <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERMIT BBj/FFFOORR'E SIGNING. <br /> Signeae�-- 'Ri " ' Phon <br /> 1st-Pennitlee(while) 2nd-Inspection(pink) 3rd-File(yellow) 4th-Finance(white) <br />