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CITY OF STOCKTON 74116 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> M 5; Go-e5 '� �1'S <br /> Applicant's Name vL�S '� DateAPPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owne ontractor Zjo <br /> Address 17YiV �J �C; si c ��✓�S'r' Phone 7o?-933 1,6 9 Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> CityState Zip Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. S� �- ����,��� of the City of Stockton Storm Water Pollution Prevention <br /> Maintenance Staff Guide, whichever is applicable. <br /> Owner Contractor Address 2o9Y.� _S. t✓;�..,r�<�-, „cam By Date <br /> CA '7037e> <br /> Estimated Starting Date Sf, ;t Yj,,o Completion Date 0a Lo!D Permit Expiration Date <br /> 01 <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> Or <br /> �Zc/�1nr/�� L✓ilI �G �acLG `� G,�i�� �0� 7����� CE'�e-�I ave Sw1'�4c <br /> /�G JzLcof (..ii�4 �e,( Low r� <br /> ATTENTION: Applicant/Contractor-you are responsible to <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ _ <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 to- <br /> Sewer Tap Deposit.................. $ <br /> TOTAL DEPOSIT ...... $ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT NOT VALID WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 931-8,W TO REQUEST A CWROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> CONTROLN <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 <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(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: o Phone: ?CTI-9__ _3 � <br /> is!-Permittee (white) 2nd-Inspection (pink) 3111-File (yellow) 411' -Finance (white) <br />