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am CITY OF STOCKTON PUBLIC WORKS DEPARTMENT 74300 M APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY Applicant's Name IfmX-r' &&Tf/ SrtP Date L l� I � APPROVED : BY THE PUBLIC WORKS DIRECTOR Address Gtpr) ' ' r P � T� Phone (O /0 S ) LI w Subject to the General Provisions and Special Conditions, , 11 �,�� / and all work must conform to the project's approved Storm N City . State �_ Zip Water Pollution Prevention Plan or the most current version Location of Proposed Work, etc. &Sla S , of the City of Stockton Storm Water Pollution Prevention ��AOf Mainte ce Staff Guide, whichever is applicable. GwoCW3 Owner/Contractor Address By ate a /v Ge Estimated Starting Date D Completion Dater l 0 Permit Expiration Date 2 is /d I (or We) hereby apply for an Encroachment Permit to carry out the following work: �N / .L L 1 C cam- VO ATTENTION: Applicant/Contractor — you are responsible to �c replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE " .. " ,, ., . . ,. . . ... . .. . . . . $ gutter from score mark to score mark adjacent to the parcel; Z remove USA markings upon completion of the permitted work. Additional Footage Fee . . .. .. ... $ The above named applicant hereby requests permission to Sewer Tap Deposit . . . ,. . .. .. .. $ TOTAL DEPOSIT .. .. . . $ S7Z� Building Permit No. Improvement Plan No. Supplemental Conditions: PERMIT NOT VALID WITHOUT A CONTROLNUMRER. CALL (209) 9378386 TO REQUEST' A CONTROL NUMBER NO LESS THAN 24 HOURS, BUT NOT IN XCESS OF 72 HOURS PRIOR TO START OF WORK. Show sketch above or refer to drawing submitted IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit, as well as all applicable city ordinances, resolutions, 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 not meet the above requirements. Failure to comply will be cause for revocation of this permit. Applicant agrees to indemnity and hold the City 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 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 of this permit. IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER, THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER. (FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS, PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT (209) 937-11411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) PRIOR TO ANY REQUIRED INSPECTIONS, AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT, PERMITTEE SHALL CALL (209) 937-8391 . ,1^ S V 0 READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT :B:EFOR::::::G;;;a� /��^ I� Signed: Phone$ W6 1st -Permittee (white ) 2nd - Inspection ( pink) 3rd -File (yellow) 41h -Finance (white)