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<br /> CITY OF STOCKTON ,
<br /> PUBLIC WORKS DEPARTMENT
<br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY
<br /> Applicants Name •; l` .h= �� fj "`''bate i r APPROVED: BY THE PUBLIC WORKS.DIRECTOR
<br /> (Owner/Contractoy) 1; ,
<br /> j�j:/� at {r phone "ic ,•�' ,:_� a G"x: Subject"to the,General Provisions and Special Conditions,
<br /> r Address l E'..-rrsr c .'....T_ and all work must conform to the project's approved Storm
<br /> City State , . Zip5�r7t Water Pollution Prevention Plan or the most current version
<br /> of the City of Stockton Storm Water Pollution Prevention
<br /> Location of Pr
<br /> oposed Work,etc.j, 1+f I I L- [, �,_ ,/� t;{J�T. E /.Maintenance Staff Guide,which ev r is applicable.
<br /> (Owne• dontractor Address fj'r �,.r•f«+i, By c- ,ac f `•' ' '�`' r mate
<br /> Estimated Starting Date `Completion Date -Permit Expiration Dgte - x
<br /> I (or We)hereby applyforan Encroachment Permit to carry out the following work 1
<br /> ^ �, (' T rte: < i� ^. f;` (. f ��• P
<br /> --- - -�,;z .�:��--�� '•�f- �.. t,:;� .� ;�:rte+ ..:a �- ,;,- ,� ` <,-g�a�•�r't3F '�- r�=t'Ei:!�ti r -�
<br /> f IR .".Y [ [ II -f 141n ftil � +�.7
<br /> ATTENTION:Applicant/Contractor—you are responsible iq
<br /> replace all.broker, 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 permittedwoFU . Addltional,Footage Fee......
<br /> The'-above named applicant hoieby. gaests peimissioe-tot "
<br /> ` L Sewer.Tap Deposit........... $
<br /> {•�: ,ci aF��.�.�.;�,� �. i"fx' yrs/�{,� .. _ ; •- ..
<br /> 'TOTAL DEPOSIT $ .
<br /> BU,i.I�Frt PirrYtjt-Not :
<br /> Improverriertit:Uri Nq
<br /> SUpplerilntal Conditions: . .
<br /> - -..�.- .a?'"rV�'c-y !.,::?.�.'.'.`,F .�x.r.�S.:-.•f2.•'< _=F=��:.�F. •,,.,i: ., vs:^'c_-.}� ... _� ���y�,_. �,.:»,-i _ �i�' r-+• ,mow •- _
<br /> Show sketch ebovo or.teter to drawing¢ubrpilted. -
<br /> i _ -
<br /> IMPORTANfi:Applicant hereby agrpes•to complywith all prgvisions of this,permf as,well as all applicable city:ordinanoes,resolutions,
<br /> Standards and Specifications currently In effect,and:to pay.to-the City its aci•ual ca$t.foi'renioval and proper rirp(acement of any.item.which
<br /> does hat meet the above requirefrlants. I=ailuie to.comply will be pause for iedocati6h'of--this permlt.;Appllcarit.agtees t0 indemnity and hold
<br /> the City harmless against any;and all losses,costs,or damages re$Ult)6 -VOW0 injury to., raq ;death of.perso nor d�amage to prgperty.
<br /> occurring at the site of,or as,a r0sult.of,wgrkto pe.. t*rtormed undei',this permit.A certificate of insurance shall be si . Mjtted_to_the'City Risk
<br /> NI'anager prior to issuance:of"this_permlt .
<br /> IF THE WORK DOES'NOT'CON(MENCE WMiliIN 72 HOUR$'OF THE ISSUANCEOFA CONTROL NUMBERJHE CONTROL;NUMB,ER WILL
<br /> BECOME INVAI;ID,AND THE PERMITTEE SHALL CALL FOR ANEW CONTROL NUMBER.(FOR CAPITAL IMPROV'EMEN.T PROJECTS OR.
<br /> SUBbIVISION`IMPROVEMENTS,PERM ITTEE.SHALLGONTACTTHE ASSIGNED CITY PROJECT.ENGINEER AT.(209)037-8411'FOR SPECIFIC i
<br /> INSTRUCTIONS PRIOR TO THE BEGINNING-OFQNY WORK.)•PRIOR�TO ANY,REOUIRED INSPECTIONS,ASAi*NTIPIED.ON THE REVERSE
<br /> f SIDE OF THIS PO4mirr,PERMITTEE SHALL CALL(209)937-8381,
<br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING.
<br /> 1 .. r �.
<br /> 'Signed: Phot :. -�iT:5
<br /> 151-Permittee (white) 2n"-Inspection'(pink) 31d=Fite(yellow) 4'h-F-inapce(white)
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