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67519CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Appplicant's Name tdmt ! eg- act �a Date_L3 1z APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (OwnerlConttrractor) //JJ__� Subject to the General Provisions and Special Conditions,and all <br /> Address A Z7 S jl a4j &rt PQ_ Phone *11 606 work must conform to the project's approved Storm Water Pollution <br /> (7 5_ Prevention Plan or the City of Stockton Storm Water Pollution <br /> city �7� �) State Zip ZlPrevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc. /�D�-r 5L J <br /> Owner/Contractor Address <br /> Estimating Startipg Date L& I� Completion Date /v 3 Permit Expiration Date �r S Z <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> The above named applicant hereby requests permission to- <br /> PERMIT FEE.................... $ <br /> Additional Footage Fee............ $ <br /> Trench Fee............................... $ <br /> Sewer Tap Deposit....................$ <br /> 0 0 <br /> TOTAL DEPOSIT.........$ <br /> Building Permit No. <br /> Improvement Plan No. <br /> r' <br /> Supplemental Conditions: <br /> l/T <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 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 /> PERMIT-IF WORK DOES NOT BEGIN 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 <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF/THIS PERMIT BEFORESIGNING. <br /> Signed: " Phone: <br /> �7 5D(P <br /> list-Permittee(white) 2nd-Inspection(pink) 3rd-File(yellow)' 4th-Finance(white) <br /> o <br />