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�•� CITY OF STOCKTON NOW 76472 <br /> C!> PUBLIe-WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY CD <br /> Applicant's Name Ad'Via,,Aad 6tGC-klvw3✓►'t-4ate 5" I i 13 APPROVED: BY THE PUBLIC-WORKS DIRECTOR <br /> (Owner/Con-{ractor) n � l e - Subject to the General Provisions and Special Conditions, <br /> Address �� �I1c inl P-0ekt+ Phone oZG�"-��. T" ���'� and all work must conform to the project's approved Storm <br /> City SbC �� C.46 stated Zip qsZ I f Water Pollution Prevention Plan or the most current version <br /> of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. �E. Maintenance Staff Guide,whichever is applicable. <br /> Owner/Contractor Address By ��u� W <br /> Date <br /> Estimated Starting Date Mary (A .'tc,I 3 Completion Date J Usf Z � ;ZU i:3 Permit Expiration Date % <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: 4 J Y"A"e'r-, <br /> 0txc Clef V-%,'--w r��\ Wc�1 Uva ttt�a 5,4c Q j �4��tGfy �T 4"44J <br /> y� <br /> v✓11 i <br /> ATTENTION:Applicant/Contractor—you are responsible to �J <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ 5 00 <br /> gutter from score mark to score mark adjacent to the parcel; 'j p <br /> remove USA markings upon completion of the permitted work. Addttienal-Feetage-F-ee 10 l�,/ $ <br /> The above named applicant hereby requests permission to: <br /> SeAMDp-Qjeagslt.........q "... $ 0 <br /> TOTAL DEPOSIT ...... $ rj��i -I <br /> r1 Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> l• CALL (203) 937--=3 TO Rr--QUEST A CONTROL <br /> NUL EER NO LESS THA«24 HOURS, 1311T Ir°;1T IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF wry, <br /> Ct iru rt <br /> Show sketch above or refer 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(209)937-8381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Si ned: Phone: .C1 60�`53-ql <br /> l51-Pprmittpp twhitpl 7nd-Incnpr tion Ininkl Ord_Filo /volln—N nth_.G;—,,,.o/,, hif; \ <br />