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�Wsv *Moo, <br /> CITY OF STOCKTON 74288 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> M5 <br /> Applicant's Name)''t_2,J 6f0FAV Date `q—/0 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contr r � <br /> bject to the General Provisions and Special Conditions, <br /> e^� and a <br /> Address Phone Sull work must conform to the project's approved Storm <br /> City ki State _Zip ,s Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, tc. 22� s r Li I 8r G of the City t Stockton Storm Water Pollution Prevention <br /> �D Maint a Staff Guide,which r is applicable. <br /> Owner/Contractor Address QB Date <br /> Estimated Starting Date 16 -1)L- ,o Completion Date /`/O Permit Expiration Date_ <br /> I(or We)hereby apply for an Encroachment Permit to carry out folkowi g work: <br /> b % " rjq e on or f' -E La S <br /> _ Owlay"VIl <br /> ` / We- <br /> 1` iC � Q r iq-q- <br /> 14: AAE 1;0 rbmer Cy C) <br /> Slly <br /> o✓`a Lqt S . <br /> ATTENTION:ApplicanVContractor—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. <br /> Additional Footage Fee.......... $ <br /> The above named applicant hereby requests permission to: Q 7 <br /> Sewer Tap Deposit.................. $ <br /> TOT��►►L DEPOSIT ...... $ S�Z <br /> �utx�lte p/Jj �✓ <br /> Stio"ii+g Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT NOT VALID WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 937-8368 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT I <br /> EXCESS OF 72 HOURS PRIOR TO START OF WOPk <br /> CONTROL# <br /> Show sketeh above or rater 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 <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(2o9)937-8381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNINt_ <br /> Signed: PhonC:2 7 3 Z q% <br /> 1S1-Permittee(white) 211-Inspection(pink) 3rd-File(yellow) 411-Finance(white) <br />