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1 CITY OF STOCKTON 2 <br /> PUBLIC WORKS DEPARTMENT 6 E v 6 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> 4opllcant's Name LN'L M WILL- Date 0:1-01•I'.)1 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> vner/Contractor) Subject to the General Provisions and Special Conditions,and all <br /> Address. ISS- Gai nd 6g= &a a w Phone 62 0)200 X work must conform to the project's approved Storm Water Pollution <br /> CityIlk b ind State 0 zip Qq 12 Prevention Plan or the City of Stockton Storm Water Pollution <br /> / A <br /> Location of Proposed Work,etc. vJe54e�rn o�vu-,L A. Prevention Maintenance Staff Guide,whichever Is applicabl <br /> CjZUA <br /> Owner/Contractor Address By Date <br /> Estimating Starting Date .. _o..f anttl 2001 Com letlon Date Permit Expiration Date <br /> (or We) hereby apply for an Encroachment Permit to carry out the following work: im6u 6d <br /> 7 <br /> n <br /> 11(JI S,_ _ In�e -6-CAlEu G \- Lclinll`T c k . <br /> s W <br /> kO <br /> i <br /> The above named appib ft hereby requests permission to- <br /> PERMIT FEE............................ <br /> . Additional Footage Fee............ $ <br /> Trench Fee <br /> Sewer Tap Deposit.................... $ <br /> f (f I- <br /> 'k SPQ al;Qt✓�I TOTAL DEPOSIT.........$ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supple ental Conditions ti <br /> ' K Cat <br /> aCfZ- <br /> Show sketch above or rotor to drevOnq submitted <br /> IMPORTAN*P 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 ofinsurance shall be submitted to the City Risk Manager prior to issuance <br /> of this permit. 07c) <br /> 10-A <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,ANI)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 /> '°ECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE$IDE O IS PE IT BEFORE SI G. <br /> 3lgned: Phone1 Z -MAC,° X�a <br /> 1st-Permittee(white) 2nd-Inspection(pink). 3rd-Flle(yellow) 4th-Finance(white) <br /> i - <br />