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CITY OF STOCKTON <br /> 5 PUBLIC WORKS DEPARTMENT a FPSY7 3 8 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGH - - <br /> Applicant's Name 5� � 'S�%/1�'jrC,�{Qy�? pateAPPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> -1 A- <br /> IL <br /> Address � �1 l irf 5S0 phone 5.x17 Subject to the General Provisions and Special Conditions, <br /> State <br /> City�(46WP�,�C, �_ and all work must conform to the project's approved Storm <br /> Zip ��Z Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work,etc. 054- S&1* (j. 2705 of the City of Stockton Storm Water Pollution Prevention <br /> )t11M �'b p��Gt Mainten a Staff Guide,whichever is applicable. <br /> Owner/Contractor Address ` By Date ? <br /> Estimated Starting Date �'_J OL ;1Ci( Completion Date n;, � (�y,� • I Permit Expiration Date <br /> I (or We) he by a ly for an E croachment Permit to carry out the following work: iTC <br /> Ins; UvVM MArhill M. _7D10 lb <br /> IM <br /> car iotyl t@ i Tut' - a 5 0 t <br /> Al7t ✓ ✓1�i will 4 0 vvt <br /> ATTENTION:ApplicanVContractor-you are responsible to <br /> replace all broken,damaged,and/or raised sidewalk,curb and <br /> gutter from score mark to score mark adjacent to the parcel; PERMIT FEE........................... $ <br /> remove USA markings upon completion of the permitted work. <br /> Additional Footage Fee.......... $ ��The above named applicant hereby requests permission to: yL <br /> Sewer Tap Deposit.................. $ !�� <br /> TOTAL DEPOSIT ...... $ 7 7 Z <br /> Building Permit No. <br /> Improvement Plan No. <br /> S t I Conditions: <br /> PERMIT NOT UALIC WITHOUTA <br /> CONTROL NU R. <br /> CALL (209) 937-LW TO REQUEST A CONTROL <br /> NUMBER NO LESS THM 24 HOURS, BUT NOT IP: <br /> EXCESS OF 72 HOURS PRIOR TO START OF MRK. <br /> Show sketch above or refer to drawing submitted CONTROU <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 CRY 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:� Phone: 65,3U)4_7,6-2q,2 <br /> is!-Permittee (white) 2nd-Inspection (pink) 3rd-File (yellow) 41h-Finance(white) <br />