ARCHIVED REPORTS XR0003365 - Laserfiche WebLink

Home Browse Search

CITY OF STOCKTON PUBLIC WORKS DEPARTMENT J APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY �i Applicant'si�lamt3 �tit s (Owner/Contractor) w.r) Date 10/13/Z5 APPROVED BY THE PUBLIC WORKS DIRECTOR Address '_ "i 14 Phone'?/6- <�a 1-t, trO Subject to the General Provisions and Special Conditions, City - t �r State �1 Zi q 7(�-p r� and all work must conform to the project's approved Storm ` P Water Pollution Prevention Plan or the most current version Location of Proposed Work, etc i! o�< <t 4'I t Ve of the City of Stockton Storm Water Pollution Prevention r t Maintenance Staff Guide,whichever Is applicable Owner/Contractor Addressf"' , f( J�/ey Date_z_ �f Estimated Starting Date 'a 1 2 S Completion Date Lf S Permit Expiration Date I(or We)hereby apply for an Encroachment Permit to carry out the following work JL I t ATTENTION Applicant/Contractor--you are responsible to replace all broken,damaged, and/or raised sidewalk,curb and PERMIT FEE $ 7-16 D O gutter from score mark to score mark adjacent to the parcel, remove USA markings upon completion of the permitted work Additional Footage Fee $ FTha above named applicant hereby requests permission to Trench Cut Fee $ Sewer Tap Deposit $ {� TOTAL DEPOSIT $ Z 3 t' I) D Bmkitng Permit No Improvement Plan No Supplemental Conditions Show sketch above-or-rarer to drawino submtl d 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 r�jlt hich 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 CRisk Manager prior to issuance of this permit PERMITTEE SHALL CALL(209)937.8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS,PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT IF 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 ANEW CONTROL NUMBER (FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(249)937-8411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK) (. READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING l Signed Phone yl 15' Permittee(white) Z"d-IrlsnPriinn fninkl gra r i„ r _11- , ,1n I ' 1068--6EG (600) 41 w-+ad-mduo,4,�l0a4S JC) l;,413 e'LS GO SO