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• I I <br /> CITY OF STOCKTON 6 8 0 1 5 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> AAppplicant's Name 'G1w br►A T-YlV O`�ate 811 G APPROVED BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> � <br /> M �, � ICT� r- � Subject to the General Provisions and Special ConcGttons,and all <br /> t <br /> Address 7U cJtet <br /> -r . w+ Phone �!133—� Q work must conform to the projects approved Storm Water PollutionCity SU�Q State ZIPJ t l Prevention Plan or the City of Stockton Storm Water Pollution <br /> r ��� _ f ���� Prevenrion Maintenance Staff Guide whichever is applicable <br /> � <br /> Location of Proposed Work,etc [O -th <br /> trS4u+ car+-u r <br /> Owner/Contractor Address 507i.&Jt°. w Y&(T t rLt z By Date ` <br /> Estimating Starbng Date Completion Date I Permit Expiration Date �� > 0 <br /> 1 (or We) hereby apply for an Encroachment Permit to carry out the following work <br /> ,tri v"c e, CPT lotaM VrIV2 � <br /> The above named applicant hereby requests permission to 13 dl <br /> PERMIT FEE $ <br /> Additional Footage Fee $ <br /> Trench Fee $ <br /> Sewer Tap Deposit $ <br /> O 4 <br /> TOTAL DEPOSIT $ �� <br /> Building Permit No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> AnySjc✓ Cam <br /> sG�t!� ,� /tea/cam'/ �.,•1-s�p�c..�-� r� <br /> Ai/ vSA- ,t&e-�""tf r 3 <br /> Show sketch above or reser to drawing submitted West 6^ 1ewo-' Off+ <br /> IMPORTANT. Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances resolutions, <br /> Standards and Specificabons 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 certtficate of insurance shall be submitted to the City Risk Manager prior to issuance <br /> of this permit <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 WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED 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 /> OCOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER (FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> BDIVISION 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 OFT PERMIT BEFORIE SIGNING (7,079/ry+� Q <br /> Signed L Phone ' " 3—�3C/1[J <br /> 1st Permittee(white) 2nd inspection(pink) 3rd File(yellow) 4th-Finance(white) <br />