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CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT 69830 <br /> �PF�LI�ATIOt*6R ENCROACHMENT ON PUBLIC RVI-IT-OF-WAY <br /> i5e,fella V <br /> Applicant's Names' z Date iV-23'3 S APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> Ow r/Contractor) 0.S Z Subject to the General Provisions and Special Conditions, <br /> A Fess one and all work must conform to the project's approved Storm <br /> Water Pollution Prevention Plan or the most current version <br /> of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. ��n k Maintenance Staff Guide,whichever is applicable. <br /> Sk <br /> Owner/ ontracto Address 16 - ��a�ea�a hire. q�`L' By Date /Z- "12-a, <br /> Estimated Starting Date -��R 0 5 Completion Date 0 5 Permit Expiration Date--Z <br /> I (or We hereby apply for an Encroachment Permit`to carry out the following work: G P T A?> S <br /> �{\; a <br /> t LA) w -r-4 �L Tt `K�� .� c1 t Q O �—{ ._. J i`E1— <br /> S-T Gonkate-, n�,k D� <br /> ATTENTION:Applicant/Contractor—you are responsible to f7 ` <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ Z <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 /> v6 <br /> C . TOTAL DEPOSIT ...... $ <br /> ✓�� ! / Building Permit No. <br /> Improvement Plan No, <br /> Supplemental Conditions: <br /> C 110ir ICA <br /> 101 7 � '�. IT Nbt vAup wrr"OUT A <br /> ,t3IVTROL NUMER. <br /> l <br /> ALL L (209) 937-M TO REQUEST A CONTROL <br /> :iUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> E5S OF 72 HOURS PRIOR TO START OF WORK <br /> �ITROU <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 BEFORE SIGNING. <br /> Signed:�4 Phone:� 3 �/ <br /> 151 -Permittee (white) 2nd-Inspection (pink) 3rd-File (yellow) 4'h-Finance (white) <br />