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5200 G 3 7!5' <br /> CITY OF STOCKTON y 6 <br /> PUBLIC WORKS DEPARTMENT Wo P <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT. <br /> - <br /> Applicant's Name 5"45(%rWVC"lyt't�rU�^� + Date '� APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) Subject to the General Provisions and Special Conditions, <br /> Address 3rd [anit�m P�Ik �rivt, �SSD Phone 5.3l1-fo7(��')GZ 1 P <br /> and all work must conform to the project's approved Storm <br /> City G~ I State _Zip 9rj ^$Z Water Pollution Prevention Pian or the most current version <br /> Location of Proposed Work, etc. eQJ4- 5,6,/4'ir Ol. :2-705 of the City of Stockton Storm Water Pollution Prevention <br /> AMaintena Staff Guide,whichever is applicable. <br /> Irt� (1b a�-i,(Owner/Contractor Address tt BDateEstimated Starting Date 14 0 db l Completion Date 0161mit Expiration Date <br /> I (or We)he eby ap ly for an E croachment Permit to cant'out the following work: ►m ! o <br /> i Im An Aikohmw C ci 4, �k c.1 S ,4, o <br /> cy ivtMLksc ✓d ' - 5 <br /> fii <br /> ATTENTION:Applicant/Contractor-you are responsible to pt' <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: /O y` <br /> Sewer Tap Deposit.......:.......... $ <br /> l <br /> TOTAL DEPOSIT ...... $ J 7 Z <br /> Building Permit No. <br /> Improvement Plan No. <br /> ( � <br /> r,7121emenWaConditions: <br /> (,,7y <br /> PERMIT NOT VALID WITHOUT A <br /> CONTROL,NU R. <br /> CALL (209) 937-LW TO REQUEST A CONTROL <br /> NUMIER NO LESS THAN 24 HOURS, BUT NOT It <br /> EXCESS OF 72 HOURS PRIOR TO START OF MRK <br /> Show sketch above or refer to drawing submitted `ON I I VU <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: � � Phone: 53,o)4&-2ob <br /> 1s:-Permittee(white) 2nd-Inspection (pink) 3rd-File (yellow) 41"-Finance(white) <br />