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- 5466 sa(lyf <br /> CITY QF'S'TO'CKTON ' - 07,0�&/ <br /> PUBLIC WORKS DEPARTMENT 70105 <br /> M05APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name A� _5 r—AVAr Date APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) ii,, <br /> Address 330 atk il. 'i#S5v Phone 5,�-06--061 Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City CA P44— State_ A Zip Water Pollution Prevention Plan or the most current version <br /> of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. 014- 51;0604 rt1( 2705 Maintena �ff Guide,whiche is applicable. <br /> 6AVIA CIA olid. � <br /> Owner/Contractor Address ►�1Qr,. By Date r <br /> Estimated Starting Date vlGompletion Date414�ate► .5-1-0 7 Permit Expiration Date �` /�`�3Z <br /> I(or We)hereby apply for an Encroachment Permit to carryput the following work: p. iU 5 _1) d wa - /&ni- lj. <br /> wws (mw-i.5 4yoah mu-0p ad-mod b ser <br /> 5 bt low `11A A f t Ad .Miv-t L60i kc �, s;�F ��I� <br /> G-111At14 WMk w-� (l t Tra r 9L70 S (61 4-4 0 )3Iu'e.! ��a/tt <br /> ATTENTION:AppllcanVContractor—you are responsible to <br /> replace all broken, 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 permitted work. Additional Footage Fee.......... $ <br /> The above named applicant hereby requests permission to: 1 ._ <br /> Sewer Tap Deposit.................. $ <br /> s� <br /> TOTAL DEPOSIT ...... �— <br /> ,b l p <br /> ermit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT NOT VAUD WITHOUT A <br /> CONTROL NUMBER. <br /> CALL. (209) 937-83135 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK <br /> Show sketch above or refer to drawing submitted CONTROLS <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 CITY 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: Sid 9, kPhone:530 676-24yoZ <br /> 1st-Permittee (white) 2nd-Inspection (pink) 3rd-File(yellow) 41h-Finance(white) <br />