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-62, bo3 3l(03 <br /> 57741 <br /> CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT 07- - <br /> M9Z - ZQ <br /> /APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> M5 <br /> Applicant's e l (N VtrCK! ble_� APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/ rac r) 11 Subject to the General Provisions and Special Conditions,and all <br /> Address /QD K ��CrD Z Phone �Z -3 work must conform to the project's approved Storm Water Pollution <br /> City14C--j7vState Cif' Zip ry S Zee a Prevention Plan or the City of Stockton Storm Water Pollution <br /> `^,� ,t_ Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc. kplp 6!T7 r'4 L k-- 5r 4 <br /> ,�N <br /> i -f- S-1 5-a <br /> f1wJ <br /> Owner/Contractor Address V 1120 Am 11 Jnr S .love i"- �44 1 N- By M_ 9��Date ^5 IO� <br /> Estimating Starting Date D 3 Completion Date 3117 Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: art U $ Sn sib l 3 <br /> lVCk..A y1WP,1fV- W't(iS 4 r Y'YI V 1 Y!V es+ <br /> vt 1•tJd l h'l a I PC ✓ti.e_t Gktw- l e c v <br /> v k-r lG t C vIC;.-z,. <br /> f <br /> The above named applicant hereby requests permission to- <br /> PERMIT FEE............................$ <br /> Additional Footage Fee............ $ <br /> / Trench Fee............................... $ <br /> eASewer Tap Deposit.................... $ <br /> TOTAL DEPOSIT.........$ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> ehec& 1450 <br /> Ar( (JsA lvallk5 Sha O Ape kee*t0Ve <br /> tvp#" CsncPlef��iw O F tivp i` (` <br /> Show sketch above or rater to drawing submitted AA Y ✓ <br /> Sltarr Bei0& CeA rIV04- SrpnWWtk" 5c^,-e01aVO4' <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 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 /> SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE THIS ERMIT EFO�G. <br /> v <br /> Signed: Phone: 77 Z �� <br /> 1st-Permittee(white) 2nd-Inspection(pink) 3rd-File(yellow) 4th-Finance(white) <br />