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CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT ` '-' J <br /> ell, <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY C R <br /> Applicant's Name r- r 12 Date t - ;t -9 60 .3 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) Subject to the General Provisions and Special Conditions, and all <br /> Address Lit C �. T} r Ev r obM Dee Phone work must conform to the project's approved Storm Water Pollution <br /> City State E ct. _ Zip. / 06 ` .:3 - Prevention Plan or the City of Stockton Storm Water Pollution <br /> Prevention Maintenance Staff Guide, whichever inapplicable. <br /> Location of Proposed Work, etc. N4 nn r L e E-=wi <br /> { H© dl o S f r^G6 •� / <br /> Owner/ Contractor Address B Date <br /> Esfimating Starting Date - ! )1 e•. rGh a9D3 Completion Date rmit Expiration Date l� <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> csb �l -ti/ o c. To rn 77ie - 6"I' A or$31crs • a� Baead owt <br /> �{ m.. xn .m or l e � .s% o •'F � l Qc �• rho rSf l' -c ! Mo + r io ri�2. r Wa /� �/ D <br /> ry r ( cb � o .Q beJ-ed < eAt I ✓< &dnKOtt Lc F_ c . mac { • �en � <br /> n / n -1 re st a � r l� to t1rJGl7 'IrzA- ;a r`o a776: l ed <br /> (3� ZF <br /> 1 Cupit Lr�4 me Owl, <br /> The above named applicant hereby requests permission to - QD <br /> •• PERMIT FEE .........:.......... ........ $ 3 g <br /> Additional Footage Fee ............ $ <br /> Trench Fee ............. ..... ............. $ <br /> Sewer Tap Deposit........ <br /> TOTAL DEPOSIT ........ . <br /> Building Permit No. <br /> it Improvement Plan No. <br /> - Supplemental Conditions: <br /> I . <br /> I <br /> fSnow 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 does <br /> not meet the above requirements. Failure to comply will be cause for revocation of permit. Applicant agrees to indemnify and hold the City <br /> 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 <br /> 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 <br /> of this permit. - <br /> PERMITTEE SHALL CALL (209) 937-6366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS, .BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE START OF WORK, AND PRIOR TO ANY REQUIRED INSPECTIONS, AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT, IF WORK DOES NOT BEGIN 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 /> f SUBDIVISION IMPROVEMENTS, PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT (209) 937-6411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING 9F?C{9Y WOBK�� ) <br /> / / r <br /> READ GENERAL PROVISIONS ON REVERSE SIDE PF THIS' IT EFORE SIGNING. <br /> Eggf ( `t <br /> � 7 <br /> Signed: i"`t _.�-�- Phone. �. <. i,: - L. fk-, - e.. L-.(. _o <br /> 1st-Permittee white 2ntl Ins ectio k -Fsc; l j- {- t+f f O ) (white) <br /> (white) d p (pink) 3rd-Elie ellow 1 4th-Finance white <br />