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L. CITY OF STOCKTO.N (0160-34-3 <br /> PUBLIC WORKS bEPARTMENY <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Aoplicant'sName r— Cf:� `�,Dig Date U7' APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> - Subject to the General Provisions and Special Conditions,and ail <br /> Address ' `::f':`if .�r`� ri;r ! �phone �r� "2 G -ti 7!v^ <br /> Lidf worK must conform to the projeixs approved Storm Water Pollution <br /> City��r n F err�+ 5"- ,s� Prevention Pfan or the Ci of Stockton Storm Water Pollution <br /> -�- - State i'�?- lip � �w �"��-,:� Qty <br /> Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work, etc.La <br /> it j�a ✓t� f i,�r-etc-!(` 5 ^il f� <br /> Owner/Contractor Address tri i y„�4 �'! „F ! !. =1. 4 B t Date �T <br /> Estimating Starting Date f'IeLl Completfon Date P=rmit Expiration Date 40 SOS <br /> I (or We) hereby apply for an E_ncroaghment Permit to carry out the following work: <br /> IL <br /> �rC <br /> LIM <br /> The above named applicant hereby requests permission to- ^. - <br /> PERMIT FEE............ .............. $ <br /> �.. Additional Footage Fee....... .... $ <br /> Trench Fee .......................... .... <br /> Sewer Tap Deposit............... .... S <br /> TOTAL DEPOSIT.........$ <br /> Building Permit No. <br /> Improvement Plan No. _ <br /> ),3rJf Supplemental Conditions: <br /> =:� .ter"• -,��vt,�.. L.�+"�u�z.� a�cst_ "� ft-lit t�inc! <br /> Shaw sketch above or refer to drawing submitted t <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit,as well as all applicable City ordinances,resolutions, <br /> Ld 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 compiy 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 EXDESS 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. EF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER, THE CONTROL NUMBER WILL <br /> 6r BECOME INVALID AND THE PE,RMI'rTEE SHALL CALL FOR A NEW CONTROL NUMBER. (FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS, PERMITTEE SHALL CONTACT THE ASSfGNED CITY PROJECT ENGINEER AT(209) 937-8411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEG1NNING OF ANY WORK.) <br /> L+ READ GENERAL PROVISIONS ON REVERSE SIDE OFTIkB'F;rERMIT BEFORE SIGNING. ^} <br /> Signed: r /,Jlrt2: Phone:_��� <br /> j„� er_Corrittga fWhlfel 2nd-Inspection(pink) ',,rc-File(yellow) 4M-France(white) <br />