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CITY OF STOCKTON 76254 <br /> S DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY� <br /> Applicant's Name *4✓*OtA 6A-DTUAP-0 Date 3 APPROVED: BYTHE FJJ�E 40 WORKS DIRECTOR <br /> (Owner/Contrawtor) p dd� �1 Sublect to the General Provisions and Special Conditions, <br /> Address e9% -) ! kAIW R - Phone 'FAQ / IO and all work must conform to the project's approved Storm <br /> City �t i State Otki-_Zip S 21S 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. Maintenance Staff Guide,whichever is applicable. <br /> t � <br /> Owner/Contra Address 4490 By Date / <br /> Estimated Starting Date 9T/ _ Completion DateLf. / Permit Expiration Date���S <br /> I (or We) hreby apply for an Encroachment Permit to carry out the following work: <br /> Ins 1 W E;r,U CS 7 M-*&i dam N0v,4-k 5;a.4 y1- rwf LV4L A4r- <br /> -,Z � FA!Iqg8s+ aF <br /> ATTENTION:Applicant/Contractor-you are responsible to --7 ®� <br /> replace all broken,damaged,and/or raised sidewalk, curb and PERMIT FEE........................... $ L i <br /> gutter from score mark to score mark adjacent to the parcel; �r Z 3 <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $ ! <br /> The above named applicant hereby requests permission to: y C <br /> Sewer Tap Deposit.................. $ <br /> TOTAL DEPOSIT ...... $ 'El <br /> Btrihiitxj.Permit No. 13 O/( <br /> Improvement Plan No. <br /> Supplemental eC'on� aU!d�itio;nys: �g +� <br /> o- lT wA°. D f HOUR <br /> T <br /> v= TO REQUEST A CONTROL <br /> t1i: 12:Fi i Iy.SS THAN 24 HOURS, BUT NOT N <br /> EXCESS OF 72 HOURS PRIOR TO START OF Wl <br /> CO TROLS— <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 itemwhich <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 PERMRTEE 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 <br /> �BE/FORE SIGNING. <br /> Signed:V 4.et�GLcylZS Phone: <br /> 1st Dm—ifton f—hitnl and_Inom—tinn fninb\ prd Ciln/,•npn...\ nm CL.....--f.....:.,.� <br />