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CITY OF STOCKTON PUBLIC WORKS DEPARTMENT PY7386 1 APPLICATION FORE O m5 s�� w/ T ENCROACHMENT ON PUBLIC RIGH - - Applicant's Name✓rit '� =11�`1/B;1r -'47 h Date (Owner/Contractor) --�— APPROVED: BY THE PUBLIC WORKS DIRECTOR Address�'�(1_ [(tdttss t iyf $'SSD phone 5.x1-fo� -�(�_ Subject to the General Provisions and Special Conditions, City VlWIi%f�d+r1 State _ and all work must conform to the project's approved Storm zip 6bz Water Pollution Prevention Plan or the most current version Location of Proposed Work,etc. etr54- g�tyN it70 of the City of Stockton Storm Water Pollution Prevention /f 6 �'��, - Mainten a Staff Guide,whichever is applicable. owwner'/Ctontractor Address ByaL 011Date7�e4 e? z Estimated Starting Date VJ 1 tq 2bt I, Completion Date mt Or t i Permit Expiration Date I(or We)he by apply for an E roachment Permit to carry out the following work: ! p v5 Ovefs U &J t ✓I i -if t, ATTENTION:Applicant/Contractor-you are responsible to replace all broken,damaged,and/or raised sidewalk,curb and gutter from score mark to score mark adjacent to the parcel; PERMIT FEE........................... $ remove USA markings upon completion of the permitted work. 2 Additional Footage Fee.......... $ J� �— The above named applicant hereby requests permission to: yL Sewer Tap Deposit.................. $ !l� TOTAL DEPOSIT ...... $ J 7 Z Building Permit No. Improvement Plan No. Conditions: I C �y PERMIT NOT YAUD M'NOUTA CONTROL NU ER, CALL (209) 937-&W TO REOLIEST A C0NTR0L NUMBER NO LESS THAN 24 HaIRS, BUT NOT IP. EXCESS OF 72 HOURS PRIOR TO START OF MRK. Show sketch above or refer to drawing submitted CONTROL#__ IMPORTANT. Applicant hereby agrees to comply with all provisions of this permit,as well as all applicable city ordinances,resolutions, 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 not meet the above requirements. Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnify and hold the City 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 of,or as a result of,work to be performed under this permit.A certificate of insurance shall be submitted to the C' Risk Manager prior to issuance of this permit. dY IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IN937-8411 FOR SPECIFIC STRUCTIONS PR OR TMO T'HE�BEG BEGINNING OF PERMITTEE ANY WORK.)RPRIOR O ANY R OLL CONTACT THE ASSIGNED UIRED INS ECTIONSPROJECT ENGINE,AAS DENAT(20TIFIE ON THE REVERSE SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937-8381. READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. Signed:_ G¢�Lf �jG� Phone: C.7,3U2 74-2o,62 1St-Permittee (white) 21111-Inspection(pink) Tcl-File(yellow) 41h-Finance(white)