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CITY OF STOCKTON 6- J I u <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> tplicant's Name <br /> Date o APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner,Contractor) ,i G 1 Subject to the General Provisions and Special Conditions,and all <br /> Address?���� S��Cr�' ���lZ Phone` ��� ��ys work must conform to the project's approved Storm Water pollution <br /> E4 _ `t�f1(� Prevention Plan or the City of Stockton Storm Water Pollution <br /> City i_ Stale Zip Prevention Maintenanc Staff Guide,whichever,is applicable. <br /> Location of Proposed Work,etc.._ r3o� trtr ��POtn ''�� • <br /> Za L <br /> Date <br /> Owner/Contractor Address <br /> ermit Expiration Date <br /> Estimating Starting Date # CS Completion Date <br /> s <br /> 1 (or We) hereby apply for an Encroachment Permit to carry out the following work: k <br /> l <br /> - '�� <br /> The above named applicant hereby requests permission to- <br /> PERMIT FEE.............................$ j Z <br /> Additional Footage Fee--....... $ <br /> Trench Fee............................... $ <br /> Sewer Tap Deposit......:............ $ <br /> TOTAL DEPOSIT;........$ 1 2 <br /> i C1 t-A r L- Building Permit No. <br /> z Improvement Plan No. <br /> Supplemental Conditions: <br /> �i®cam No Id�►�. c.lasvres arc, P�r+u{�e�Q, <br /> r Re"%-a it- A-V%J rr 4c �G.CL di,11 CIA ed <br /> s hA etJA1 k. <br /> Show sketch above or reser to drarimg 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 because for revocation of permit.Applicant agrees to indemnity 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 B F'SIGNING. <br /> Signed: Phone:w[. G L� fix$ "} 7 a. <br /> 1st-Permittee(white) 2nd-Insbection( ink) 3rd-File(yellow) 4th-finance(white) <br />