Laserfiche WebLink
b st' Dbo 525 <br /> CITY OF STCKTON <br /> DEPART 733415 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> C.D N'Ee stu,� <br /> Applicant's Name n5 OGtcLt- Date tb alo-1X1 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor D tnv E- #-2-Bb Subject to the General Provisions and Special Conditions, <br /> Address (G u Lj. I(Ll oey-srzU Phone and all work must conform to the project's approved Storm <br /> City S C)KS cw-yla State Cor _Zip�} Water Pollution Prevention Plan or the most current version <br /> a,1q,4 FCLST ��mD�,y-, of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work,etc. �•1 J Mainten cs Staff Guide,whichever Is applicable. <br /> Owner/Contractor Address By Date <br /> r�l - 1- 1c) <br /> Estimated Starting Date Compleiion Date 'J-d Li, Pet F�lpiration Date <br /> I(or We)hereby apply for an Encroachment Permit to carry out the following work: <br /> �• 33-a 3`� <br /> ATTENTION:Applicant/Contractor-you are responsible to <br /> replace all broken,damaged,and/or raised sidewalk,curb and PERMIT FEES...................... $ z <br /> gutter from score mark to score mark adjacent to the parcel; fC <br /> remove USA markings upon completion of the permitted work. Acid Tral-Foetag/�j'1/��J���''`�. $ <br /> 1Te above rmmed applicant hereby eaquecte Perm6 / C <br /> vlee to: v r S <br /> $ <br /> Sewer Tap Deposit.................. <br /> Sto _ it�c�os�d TGA . // -- <br /> TOTAL DEPOSIT ...... $ �"J �Z lJ/ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT HOT VAUD MTHOUT A <br /> CONTROL NUMBER. <br /> CALL (208)9374W TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT li <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK, <br /> CONTROL# <br /> Show OM h above or rater to dmwine nvb.leed <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 /> i 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 OFA CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> BECOME INVALID AND THE PERMITTEE SHALL CALL FOR ANEW 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 REOUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE <br /> SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937.8387. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. --t1 -737--361 3 Z- 7a�61 <br /> Slgned:F �nx O Phone:_1154 �_786ij/0 <br /> 1� -Permittee(white) 2nd-inspection(pink) 3`"-File <br /> `(yellow) 4t4-Finance(white) �� <br />