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L. 7-Kjt �b 6�1U,51W5b66e <br /> S CITY OF S ST68 `) <br /> DEPART PUBLIC WORKS DEPARTMENT n_ _, bj-CWoW <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY �Q•U'-lJ <br /> Applicants Name AD "NC o Y� I>4\_ane4- Date 5-3--o 7 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) I4 ee+Tpu,-,Imc. Subject to the General Provisions and Special Conditions,and all <br /> Address R i T 5u C.al ?.Q8%0 Phone(w2�4161-t ooc work must conform to the project's approved Starm Water Pollution <br /> Prevention Plan or the City of Stockton Storm Water Pollution <br /> City__�5Ly State__f..Pk Zip q 2-15— Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc.gOsl.t F V8a D Atircmert'x�LE S�.';fSv rs / 'y,,r�� e-1151 + .r v r LOVES al vn STocxrora Ge 8520+3_ /�rG� 6 7 �� <br /> Owner/Contractor Address ;TQll-:tt-PF&QY.ER ___ By-'7 Date - <br /> 1-7 <br /> Estimating Starting Date 7 '7�d/ Completion Date dy-l Permit Expiration Date3_7 <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: .T N 4Tof <br /> C')NE 7 7NCf-L.-;,'VC f (Z-GvlNj�_ � f�'C F12 MCtlT Te 1ZTN C- WPII <br /> The above nametl applicant hereby reeoests pRmi"im to- 3 3 <br /> PERMIT FEE............................$ _ <br /> PLEASE SEE ATTACWE:D WOR-14, PLAN D` <br /> D AT SO 15 ;T A 1V V AP Y 20C�1, Additional Footage Fee............$ o+ <br /> Trench Fee............................... $ <br /> Sewer Tap Deposit.................... $ <br /> TOTAL DEPOSIT.........$ <br /> ✓ ✓f so <br /> Building Permit No. <br /> Improvement Plan No. <br /> RSA jl�r ttAfMUT A <br /> ,014TROL NUMBER. <br /> t.L (209) 937-M TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOII <br /> x;FSS OF 72 HOURS PRIOR TO START OF WORK. <br /> Snow sketch above or refer to drawing.uIxb led <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. <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 IDENI"IFIED 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 BEFORE SIGNING. <br /> Signed: Phone: (2CZJ) 44C 7'1C7C>E. <br /> 1st-Pennine(while) 2nd-Inspection(pink) 3rd-File(yellow) 4th-Rnance(white) <br />