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%.901 64b <br /> CITY 6F, CKTON 68243 <br /> PUBLIC WO ii��55 DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Apwn'hcanl'a Names S Fh�irr,�, � C_ Date �- 5-DS <br /> er/Contracctor) APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (O <br /> Address 333G „- Ge 1 Fir Sv P ones 30 r Subject to the General Provisions and Special Conditions,and all <br /> work must conform to the project's approved Storm Water Pollution <br /> City �kState C4 zip 1 p 56 V Prevention Plan or the City of Stockton Storm Water Pollution <br /> Location Of Proposed Work,etc. t (J7, <br /> j w�!I� &S iT / 2-705 Prevention Maintenance Staff Guide,whichever is applicable. <br /> _JvLakri. n'.'L P IJd. V <br /> Q r <br /> Owner/Contractor AddretkT4 ��T <br /> S 5Q Iia Rd, ; tai <br /> BY Date�7 <br /> Estimating Starting Date Completion Date ' W r Permit 0— <br /> AE�xpiration Date_ t' � 0�— <br /> I (or We) hereby apply for an Encro chment Permit to carry out the following work: A . 5 a i l <br /> i �' 2 <br /> Ub 4 y i A ^ <br /> W v�:tet <br /> IV VC. 1 fis -0/t. &,Vn <br /> ,he above named appikent hereby requests parmissbn to. -Z ? o� <br /> PERMIT FEE............................$ J <br /> Additional Footage Fee............ $ �- <br /> Trench Fee............................... $ <br /> Sewer Tap Deposit.................... $ � <br /> Z3G m <br /> TOTAL DEPOSIT.........$ -� <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> See 5i kPi4,A <br /> Slaw sketch above or rotor to drawing submitted <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 most the above requirements.Failure to comply will be came for revocation of permit.Applicant agrees to indemnify 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 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 /> BECOME INVALID AND THE PERMITTEE SHALL CALL FORA 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 <br /> )�-PERL41T BEFORE SIGNING. S /-}� <br /> D JI <br /> Signed:_ taO7/ UA�`tn/— Phone: v30'(O/lel -2016 <br /> 1 st-Peru ttee(white) 2nd-Inspection(pink) 3rd-Rie(yellow) 4th-Finance(white) <br />