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I <br /> CITY OF STOCKTON 71445 <br /> li PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> i � <br /> Applicant's Name Ccr / loYNra 7Lt 7kL 'J+nDate /o / o APPROVED : BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> - Address 3 /0 j S . Oe4, I�ZYWO Phone Subject to the General Provisions and Special Conditions , <br />( and all work must conform to the project's approved Storm <br /> City STpC /i ToN State C/�_ Zip g � ;to� Water Pollution Prevention Plan or the most current version <br /> I of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. _ Qo f/q $�a/�. r o/ Maintenance Staff Guide, whichever is applicable. <br /> S. ILUog4od <br /> Owner/Contractor Address ate -P7 <br /> Estimated Starting Date _ ZQ192, ,y Completion Date /O/,?5 D Fermi Expiration Date 17 (S c,7 <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: r-f d yq m e <br /> ` ��//..,, OYi ryS.Jr / o <br /> & MAA'/ lifd + C /C ,4 L4 Or / 2j; ` / o s ier-e So /V dhU/ Glfi�cCnr� WG fC✓ <br /> Saw Ves — twc oa 14e walkway on It-4e west cede of S I Lborefrn sF <br /> aha OhE 01, 1F4e &Iirt ease . I o✓j'01 � c Ly ,'I/ Ae CIVS- eel l v 'A • en, e y <br /> aroecf rf '7lre Cu.� �INCI vt of >r/re wov/r <br /> ATTENTION : Applicant/Contractor - you are responsible to - <br /> replace all broken , damaged , and/or raised sidewalk, curb and �3 ma <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . $ <br /> PERMIT FEE <br /> gutter from score mark to score mark adjacent to the parcel; <br /> remove USA markings upon completion of the permitted work. <br /> Additional Footage Fee . . . . . . . . . . $ <br /> 1 The above named applicant hereby requests permission to <br /> Sewer Tap Deposit ' , . , , " , , . , , , , . . . $ <br /> JAG C( (/ 4 CFCC% /=i " W YP � �'O ✓ � Ofy <br /> J TOTAL DEPOSIT . . . . . . $ 3 <br /> /0Caf'4PH o//� ,Oe) eInSS . <br /> Building Permit No. <br /> Improvement Plan No. <br /> lorot1l %c% d US 510wn oil a / /4c�pJ Supplemental Conditions: <br /> PERMIT NOT J€ UD WITHOUT A <br /> CONTROL HUMMER, <br /> CALL (209) 937-8366 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> pEXCESS <br /> )OFt 72 HOURS PRIOR TO START OF WORK. <br /> Show sketch above or refer to drawing submitted4a1.�.�PVcI I\®6 , SS / 0 9 0 <br /> IMPORTANT: Applicant hereby agrees tcomply with all provisions of this permit, as well as all applicable city ordinances, resolutions, <br /> o <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 REVE <br /> SIDE OF THIS PERMIT, PERMITTEE SHALL CALL (209) 937-8381 . RSE <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> ne <br /> I <br /> Si9d: <br /> Phone. 20q YC < _ }Sf <br /> y <br /> � <br /> 1a� - Permittee (white ) 2nd - Inspection ( pink) 3m -File <br /> (yellow) 4m -Finance (white) szti <br />