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l <br /> D <br /> CITY OF SAC2 <br /> ON 5t� <br /> PUBLIC WORKS D` P TMENT APR <br /> 8 6643 ! <br /> M15 APPLICATION FOR ENCROACHME O PUBLIC RIGHT OF-WAY <br /> Wks�esn E�1(VIRO�IP4 <br /> Applicant'sN a ��''�� Liaesf Date y'J8'.zoo/ f�; Flt l3��7 <br /> (Owned ra } APPROVED: BY THE �UBL1C'WORKSb` MECTOR } <br /> 1 trt4 CJ <br /> Address �e�si-jC� Sfr�e �r , Subject to the General Provisions and Special Conditions,and all <br /> / O Phone ff`S3 work must conform to the projects approved Storm Water Pollution <br /> City—(�po`�i�hv State C'y Zip '?S'7 74cr Prevention Plan or the City of Stockton Storm Water Pollution <br /> S�' <br /> Location of Proposed Work,etc. /VoxPrevention Maintenance Staff Guide,whichever is applicable. <br /> ��i �c.g�4f <br /> Owner/Contractor Address *"Xrl: B Date 1 <br /> Estimating Starting Date 4'0"'l Completion Date A d,22'7 200 <br /> ermit Expiration Date — " <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: fle►.41►r t e4,1g./ asp,/ fa ir/ <br /> a a o G� Ell, <br /> V/111 <br /> -/� a a de A v7e /5v e� c c e� <br /> '`e <br /> The above named applicant hereby requests permission to <br /> PERMIT FEE............................$ <br /> Additional Footage Fee............ $ <br /> Trench Fee............................... $ <br /> Sewer Tap Deposit.................... $ <br /> Iv �, TOTAL DEPOSIT.........$ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <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 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)937-8366 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 IDFNTIFIFn ON TNF arvracF ctnF ne Talc <br />