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CITY OF STOCKTON 68243 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> 4pplicant's Names-6k-� all i mist!ig , - Date APPROVED BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> 33� ���� U' � <br /> � � `,t�p ��� ,� Sub)ect to the General Provisions and 5pectal Condt6ons and all <br /> Address �} i , 1, t 1'i.! Phone F? Cl work must conform to the projects approved Storm Water Pollution <br /> City C�ffitii.f.Li+l 1 JLr State_l� Zlp 7 Prevention Plan or the City of Stockton Storm Water Pollution <br /> ( �( � { Prevention Maintenance Staff Guide whichever is applicable <br /> Location of Proposed Work etc a T <br /> L'LSLR rL4 uk 9141d, - / r _ <br /> Owner/Contractor Address r < 1-S��L I R q //A�4eDate <br /> �5 + � iU? By <br /> Estimating Starting Date 1� . _. Completion Date_ Permit Expiration Qate <br /> I (or We) hereby apply for an Encroachment Termit to carry out the following work AA v" 5 c, &I <br /> p <br /> .n y b f w . W1 k e <br /> PP-4 4,cIf <br /> f 10 ct e- �( r fi ► ``� y'�l I'1/ (/c� fi5 c/L �� n �r(� �— /�y <br /> The above named applicant hereby requests permission to <br /> i PERMIT FEE $ <br /> Additional Footage Fee $ Y <br /> Trench Fee $ - <br /> Sewer Tap Deposit $ <br /> 23G m <br /> TOTAL DEPOSIT $ �— <br /> Building Permit No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> See 5tkpl" <br /> Show sketch above or reser 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 meet the above requirements Failure to comply will be cause 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 /> RMIT IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER THE CONTROL NUMBER WILL <br /> OME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER (FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> dDIVISION 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( f� <br /> THIS PERMIT BEFORE SIGNING <br /> Signed-so F- 1 _Phone 5'�a0,,7 <br /> 1st Permittee(white) 2nd inspection(pink) 3rd-File(yellow) 4th Finance(white) <br />