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S CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT 7 1 0 9 2 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> ,� <br /> J / r <br /> Applicant's Name 1 4t''V21) ( � bI aIrl6h'it�a�iate APPROVED : BY THE PUBLIC WORKS DIRECTOR <br /> i (Owner/Coprynt•r}acto <br /> Address 1 p6 r) j k 7, j0a `xa. Subject to the General Provisions and Special Conditions, <br /> L) 9 �1P�hone ? 97 and all work must conform to the project's approved Storm <br /> City .. �re,,�'TVJ.J State S Zip /Sr;7/S Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. 7 ` 1 of the City of Stockton Storm Water Pollution Prevention <br /> P A1 ,Q ' `� �S/O Mainrra@ce -Staff Guide, whichever is applicable. <br /> iiatilx3l /� ay .5. e/ ".AbD 1 SirW / % / // / Gam} ©7S <br /> OwnerlContractorRddress �f fi' By �C f ���G G `!' pate / <br /> Estimated Starting Date 17k£b ,;20 `�'' Completion Date 4 " 6 'Vg Permit Expiration Date t-%-% - Eat <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> t e+�Vzanl��itie St�i/ G��r>' x s 'Ae %rr2 0aivf4ol Z `r;l 404 lA i _41 <br /> .S6 it ie c raxix eo ' An WS{& Gkks✓ . w� 1�2 . > ) lle4e erg <br /> ei'�'c�c�t dL clrrt/ _fly.'/ Setryly/ i:✓ ` e 4?y <br /> ,...� dl /!?r'✓ii :� c�1C��7,✓�i�J-L�f•� ..5� Ei i-z�iX � e�%n q ��/L �7`: <br /> ATTENTION : Applicant/Contractor - 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. Additional Footage Fee . .. . . . . . . . $ <br /> The above named applicant hereby requests Permission to <br /> Sewer Tap Deposit . . " ,, . . . . . I .. .. .. $ <br /> TOTAL DEPOSIT . . . . . . $ <br /> Building Permit No . <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT NOT VALID WIIOU €' " <br /> CONTROL NU SER, <br /> CALL (209) 537-SM8 TOREQL;ESI A GONiRO_ <br /> NUMBER NO LESS THAN 24 HOURS,- BLIT NO" i <br /> jE`X)'C�EfSS�jO�*Fp 7,(2� HOURS PRIOR TO START OF N?GRIN' <br /> Shaw sketch above or refer to drawing submitted `"`'�" ' o I rlA.:4,75' <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 FORA 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 /> { � -/ I <br /> Signe; , le drrL X• l Phone, <br /> let - Permittee (white) 2nd -Inspection ( pink) Td -File (yellow) 4th -Finance (white) <br />