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67678 <br /> MIA <br /> CITY OF STOCKTON DEPART <br /> PUBLIC WORKS DEPARTMENT 6nMi5sZ <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY 6WO77,562- <br /> M5 <br /> Applicants Name (� r/ 8(Gly/ Lam' Date / �6 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor Subject to the General Provisions and Special Conditions,and all <br /> Address �- e ` hone `" /3 y� work must conform to the projects approved Storm Water Pollution <br /> `�'�_ Prevention Plan or the City of Stockton Storm Water Pollution <br /> City_ST�CieTd�i/ State Zi P �S Prevention Maintenance ff Guide,whichever is applicable. <br /> Location of Proposed work,etc. <br /> 75- <br /> Owner/Contractor Address / By Date <br /> Estimating Starting Date / Completion Date rmit Expiration Date <br /> Y <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> bZ— �` -5/-'tV C1 zY67,e TAr—//L. Gtl <br /> The above named applicant hereby requests permission lo- <br /> PERMIT FEE............................$ ✓ <br /> Additional Footage Fee............. $ <br /> �...K�C� „r ,/ / / Trench Fee.............................. $ <br /> /Jy,(P"61.rH.(^,'t'`�[,(^•l' Sewer Tap Deposit.................... $ Oxy <br /> TOTAL DEPOSIT.........$ l�c/ 00 <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> A aur <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 indemnity 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 OF THIS PERMIT BEFORE SIGNING. q <br /> Signed: S2 Phon a ) -),/� <br /> 1st-Permittee(white) 2nd-1 pection(pink) 3rd-File(yellow) 4th-Finance(white) <br />