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CITY OF STOCKTON 71131
<br /> M PUBLIC WORKS DEPARTMENT
<br /> yAPPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY
<br /> Applicant's Name 5'§J6 EvlVrrva,nvr44Uj J^( Date APPROVED : BY THE PUBLIC WORKS DIRECTOR
<br /> (Owner/Contractor} f �1
<br /> Address �. . C.tf t�M1 +S O7tiilG !✓t'• i #SoPhone Subject to the General Provisions and Special Conditions ,
<br /> I and all work must conform to the project's approved Storm
<br /> City - Calox� RJ( State - CA- Zip `5G �L, 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. Abit^ in tFSeG. S t d i Mainte
<br /> ^r ARa
<br /> nceSStaff Guide, whichever is applicable.
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<br /> Estimated Starting Datek! ✓P t Completion Date Permit Expiration Date
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<br /> I (or We) hereby apply for an Encroachment Permit to carry/out the following work: T4ro !a , s 3 ce < t rYyt'P
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<br /> ATTENTION: Applicant/Contractor — you are responsible to $ ��
<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;
<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 /> n TOTAL DEPOSIT . , . , ,, $ o
<br /> totkfittg Permit No .
<br /> Improvement Plan No,
<br /> Supplemental Conditions:
<br /> PERMIT NOT VAUD W-11
<br /> CONTROL NUMBER.
<br /> CALL (2gg) 937t86g TO REQUES1 Aa 10 R ROL
<br /> NUMBER NO LESS . i r4AN' 204 1 OUPS, BUT NOT IN
<br /> E�wwX?C@ESS OF 72 HOURS PRIOR TO START OF WORK
<br /> sketch above or refer to drawing submitted C H4TR0 g .
<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 S, IIIGG�N�IIN��//G. ,
<br /> Signed: 5 w ;'J6'4"t i� Phone:53047trG Oq"&z
<br /> is' -Permittee (white) 2n6 -Inspection (pink) 3rd -File (yellow) 411 -Finance (white)
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