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CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT 70498 <br /> ^ APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> M5 <br /> Applicant's Name A�ir`anCe I G QecytAv,l,00&11461 Date f�-ll_0 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> Address S131 Shaw l2ouc� Phone q&3-10-06 Subject to the General Provisions and Special Conditions, <br /> L (Aand all work must conform to the project's approved Storm <br /> City S' yCyhl" State�Zip '5)L15 Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. :tt Ih CIA-4 Ck 5�A4V\ of the City of Stockton Storm Water Pollution Prevention <br /> Mainten nce Staff Guide, whic.1>ever is applicable. <br /> Owner,/Contractor Address By lle�l a te <br /> ` <br /> Estimated Starting Date Completion Date f- f 1'a0 0G Permit Expiration Date 7 <br /> 1 (or We) hereby apply for an Encroachment Permit to carry out the following work: S Ilk_ G ail SO f 1-41 9'r- <br /> AAvo,AuouAV o4 5 sc,I horla_s +b `3041fei �P_ Cw turf ce o 'Z Ur1 ,I>ti '�� <br /> S►�eu.�tljL.(�r cc&O2 CA s6t and QpokR& W14T- sa�v ply, fl()wiles l A017 `. <br /> �- b6TIAQs 1N,ihir AAIz f A, WAV—jire6 c0ytceor t f w qll SAXUAIc acwss <br /> a.vu& a00S <br /> _ � 1 �►Ztd.� S-�cee�-. <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.................. $ <br /> Icy bc See_ a}�C�L•� c� Mou r TOTAL DEPOSIT ...... $ <br /> It, Building Permit No. <br /> 5 Improvement Plan No. <br /> Supplemental Conditions: <br /> mC'l/t�r ' SCeF� /1'fpt/l�✓ <br /> C01HTROD L N U&,@BBER. <br /> CALL (200) 937-e WM TOREQUEST A CONTROL.. <br /> NUMBER h40 LESS TFLAN 24 I-gOUPS, BUT P,OT i!,l <br /> EXCESS O'=?2 HOURS IP-M tR T O STARE OF tIWPI', <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 B ORE SI NTNG. <br /> (. M_�f <br /> Signed. Phone: <br /> 1St -Permittee (white) 2nd-Inspection (pink) 3rd-File(yellow) 41h-Finance (white) <br />