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CITY OF,STOCKTON <br /> PUBLIC WORKSDEPARTMENT 70059 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name 0167a Ji1J1h�-0UM kf,�nepate 3I pjo APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (6L�er/t`,�rtttSet�l�,e!- (('' CC , <br /> Address 4910 W t W L►N tV6�4.tPhonel',91b _ 30'(.u�b Subject to the General Provisions and Special Conditions, <br /> '-1 q� r " and all work must conform to the project's approved Storm ) <br /> City a DO e?aVO WILL-4 State Zip 19-7 7� 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. Z 7-%4!5 J;,wart r auf�jt Maintenance Staff Guide,whichever is applicable. <br /> tw�wstvE�'ovt v��`Knr� <br /> wne ContractorAddlgsg 1K IIJG By J0,1/,11W1 r XMate <br /> Imated Starting Date _ n, Cotmpletion��Vig-O(. :Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: ` <br /> vu Du i(AU)-4 IA&. VAe, AA QA_ i r�frtc0�.tn moo. 2Z5 <br /> ek <br /> i• <br /> replace all broke , damaged, and/or raised sidewalk risible to p <br /> ATTENTION:AnIlcanVContractor-you are responsible <br /> icurb and PERMIT FEE..........:................ $ 77Z-0 00 <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.................. $ <br /> TOTAL DEPOSIT ...... $. Tito om <br /> Buiidirtg Permit No. D6 �7VV <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT NOT VAUD WITHOUT A { <br /> CaNTROL NUMBER. <br /> CAU. (209) 937.8366 TO REQUEST A CONTROL l <br /> NUMPER NO LESS THAN 24 HOURS, BUT NOT IN <br /> i_YCESS OFF 72 HOURS PRIOR TO START OF WORK. + <br /> Show sketch above or refer to drawing submitted GONTROL# M <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. <br /> 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 <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 /> I p <br /> Signed: Phone 416 `39`?A 71D <br /> 1�'-Permittee (white) 2n°-Inspection (pink) 3r° -File (yellow) 4'^ -Finance (white) <br />