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FjAl <br /> ass" <br /> CITY OR TOCKTON . 67756 <br /> PUBLIC WORKS DEPARTMENT <br /> M05 APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY J!2$OOj�jp3 <br /> gpplicanCs Name ICL % .If SkSMA Date 11:7--)u3 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/=M'0Cmr) Subjec, <br /> Address 'Z 2V Fz. lug`(P--tZ.E cT. Phone 4?qb-1345' "m me General Provisionsr*d arid approved <br /> cations'and an <br /> work must conform m the project's approved stone water PalhNort <br /> city ' 'Tip C.tnSbra State C4 Zip f i.40 c Prevention Plan or the City of Stockton Storm Water PoMt5on . <br /> Prevention Mainte Staff Guide,whichever is applicable. <br /> Location of Proposed Work,em. ilW Ln�P� OE h'VIRX.I=.y_ <br /> Si'S�f�6- 5 fiL.G Fes?i S rYt 6ri <br /> Owner/Contractor Address_UZT- E NA-tltruF— c-r S` OCZVA,0 Date .4471 <br /> Estimating Starting Date�I?/o3 Completion Date 3 2 3 - Permit Expiration Date 'Jr - <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: i c4S1 <br /> Ste. o3-Qs t�� <br /> ,he MOM named appNrant twe y ffi,em WrmissNn to- PERMIT FEE............................$ <br /> P91, Jon_ <br /> Additional Footage Fee............$ <br /> Trench Fee............................... $ <br /> Sewer Tap Deposit....................$ <br /> STOTAL DEPOSIT.........$ AK e)o <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: 11 ' <br /> A)o WW_ CIoslAKS 8K-`�ervti`1t�1, <br /> Show"Ch above or Mar to ftkV submMW J<I '-` ^�.� ay <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 roes <br /> not mast the above requirements.Failure to comply will be cause for revocation of permit.Applicant agrees to indemnify and hold the City- <br /> harmless <br /> ityharmless 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 pemhit.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 OFA 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 OF THIS PERMIT EFORE SIGNING.. - <br /> Sdgned: <br /> 1st-Permittee(white) 2nd-I tion(pink) - ile(yellow) 4th-Finance(white) <br />