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- St2 O60l�f 9 <br /> CITY OF STCKTON <br /> DEPART 73856 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> M15 (TXe S-eo.ee G.oy a...) <br /> Applicant's N e �f dAm Ana a Date �/ o APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/ ontract ) s4ife N <br /> Address f5/y f1.Cna.fnv.. <br /> red, Phone(S30272-420o Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City GrL14* State CA. Zip 9'S9V 9 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. �e.�. 1a Mainten a Staff Guide,whichever is applicable. <br /> ��aygractor ss 2 oSrr C�. Ha,..4".�St. ,d ee,, ,0.�' y ���11�a -< 3wn /ContractorAddress soS.V Lnd e-� Ln. U6/H4'jfYfe cA 9yS9f Be O�/ <br /> Estimated Starting Date lye /O. solo Completion Date Z /. 120!0 Permit Expiration Date 7 <br /> I (or We)hereby apply for an Encroachment Permit to carry out the following work: <br /> 1"A4 &! llon>`e FOO4IS St /0e&'A4/ a'f' //O b. F.'/6e f SR y ��n.4fon 44 inns;s fii n OT rn vete it <br /> oiack Asrm ae in nel we// o ✓a lzie-*on i,,rN 6e, <br /> OA,,iA10 1 <br /> H H . <br /> ATTENTION:Appli nVContractor-you are responsible to - O� <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ S <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.................. $ ( d <br /> 7zBuiGJ <br /> TOTAL DEPOSIT ...... $ -57Z- <br /> Building <br /> lding Permit No. <br /> Improvement Plan No. <br /> C Supplemental Conditions: �y / <br /> PERMIT NOT VALID WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 937.8386 TO REQUEST A CONTROL <br /> NUMBER No.LESS THAN 24 HOURS, BUT NOT ii <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> CONTROL# _...-- <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 <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. -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 I <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 SIGNING. <br />