Laserfiche WebLink
hil, *!. ZRIE "J TVFD <br /> ASCITY OF STOCKTONAY 4 2 Q Q1PUBLIC WORKS DEPARTM66!�87 <br /> ib AP LICATiON FOR ENCROACHMENT ON PUIGHT-OF-WAYi�o <br /> Cs Name <br /> ( 1Contractor) V'fo\ ate t 1:7 101 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> Address'X Q£� S-t`t'�►��` Phone-70-7 � 3_ �lec:t b the General Provisions and Speciai Condtions,acrd all <br /> cityS m must conform to the P uOds approved Storm Water Pdmon <br /> State CA zip 7{� Prev Plan or the City of Stockton storm water Pollution <br /> Location of Proposed Work,etc TAT% 5-t-Q -- Sjn- A, PMVentron Maintenance Staff Guide,whichever is applicable <br /> S doe k VoN <br /> Owner/Contractor Address <br /> Estimating Starting Date e10 ` Date <br /> Completion Date Pemrit Expiration Date <br /> I (or We ereby apply for an Encroachment Permit to carry out the following wooyyf, 'W."1140114 <br /> rk $ <br /> VS S ' OA-&-C 1 s <br /> I he above named aPpr—M hereby—KmnM pwmms on to" <br /> PERMIT FEE $ <br /> Additional Footage Fee $ <br /> 6` Trench Fee $ <br /> Sewer Tap Deposit <br /> $ <br /> 9 TOTAL DEPOSIT $ \Z.% d <br /> BuildingPe <br /> and tins;No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> Shaw&RIch above or rent to&awrp submkted <br /> IPORTANT Applicant hereby agrees to comply with all provisions of fhls pemrit,as well as all <br /> MWWds and Specifications currently in effect,and to applicable City ordinances,resolutions, <br /> I meet the above requirements Failure to Pay to the City its actual cost for reanpval and proper replacement of any item which does <br /> rmless against any and all losses,costs.or � be cause for revocation of pemut.Applicant agrees to indemnify and hold the City <br /> or as a result of,work to be performed under oft remMki9 from injury to persons,death of person of damage to property oocurrirrg at the sate <br /> Tris permit, , pennrt A cert+ticato of insurance shall be submitted to the City Risk Manager prior to issuance <br /> RMFTTEE SHALL CALL(2o9)9374366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, <br /> IOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERES=SIDE OF THIS <br /> RMIT IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> COM INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER (FOR CAPITAL.IMPROVEMENT CONTROL <br /> PROJECTS OR <br /> BDf N IMPROVEMENTS,PERMLTTEE SHALL CONTACT THE ASS#GNED CITY PROJECT ENGINEER AT EM NT PR <br /> CI STRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK) ) 11 FOR <br /> SD GENERAL PROVISIONS ON REVERSE SIDE OF THIS PE SWT BE RE SI KING. <br /> Signed <br /> Phwe `7n in21.7 <br /> 1st-Permittee(white) 2nd-inspecwn(pink) 3rd-FNe(yam) 4th <br /> Fkrarrce(white) <br />