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Gp CITY OF STOCKTON 76860 <br /> S DEPARTMENT <br /> APPLICATIOIN FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> y -k-wLu r <br /> tht's NameCteArasler'o-n2A-� e / yIZ 3 APPROVED: BYTHE4U8HG'-VM9RKS DIRECTOR <br /> r/Contractor) ?f,132 yc <br /> ress 93;x' b lt02!L moi:—,.t ,,we Phone d C-- Subject to the General Provisions and Special Conditions, <br /> / _ and all work must conform to the project's approved Storm <br /> pity /7T „yc 7�y State�`�_Zip!Z,5-3 J-6 Water Pollution Prevention Plan or the most current version <br /> r of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work,etc. e""" Maintenance Staff Guide, whichever is applicable. <br /> Owner/Contractor Address e'.- By W l" 1�0�y Date <br /> Estimated Starting Date/4/1�/3 Completion Date X15/i Permit Expiration Date <br /> r <br /> I(or We)hereby apply for an Encroachment Permit to carry out the following work: �A9Ii : T J s Go Irn!Q�412ZZ r. ,;E-- <br /> cf _ <br /> ATTENTION:ApplicanVContractor—you are responsible to 5'z� <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, 3f] 23 <br /> remove USA markings upon completion of the permitted work. Fee... _11 <br /> The above named applicant hereby requests permission to; C" $ lU <br /> pn s� <br /> Pr,// 7� 45 i:N/T11 !,z a4�7V7,/15, TOTAL DEPOSIT ...... $ 7�2 u <br /> Building Permit No. <br /> TPl" Improvement Plan No. <br /> )le,7,14 116,le 4,//// Zee 6rdf11111-d Supplemental Conditions: <br /> A Ccnacl. <br /> EXCEER NSS 71IVoRP-Irlu!�QD <br /> �IhC c'fo�'I;>. 1 <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 indemnity 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.Acertificate 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 IS PERMIT,PERMITTEE SHALL CALL(209) 81 <br /> RK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE <br /> SIDE <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Signe Phone:Phone: <br /> s-W FOV-.P 9-S '6243 <br /> 157-Permittee(white) <br /> 2nd-Inspection(pink) 3rn -File(yellow) 41h -Finance (white) <br /> ��� -- <br />