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CITY OF ST©CKA <br /> PUBLIC WORKS DEPARTMENT—. <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name '-� 1� loDate APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> t �� �,� s.��,�Z� Subject to the General Provisions and Special Conditions,and all <br /> Address <br /> A L� t u II �J Phoney work must conform to the projects approved Storm Water Pollution <br /> City !V� a State '* Zi L S Zi� Prevention Plan or the City of Stockton Storm Water Pollution <br /> p Prevention Maintenance Sta Guide,whichever is applicable. <br /> Location of Proposed Work,etc. 5 i f i WL�� 'S � �s a 5r �{74 . <br /> Owner/Contractor Address L�' � � �� - >}tz B Date l C/ <br /> Estimating Starting Date �Z Completion Date i� e P rmit Expiration Date Z O <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: ACA <br /> u: <br /> `tlk :1 b k cj,wt,-1 t01\/e lty� <br /> -.6.AA <br /> The above named applicant hereby requests permission to- <br /> PERMIT FEE............................$ <br /> Additional Footage Fee............ $ <br /> tr <br /> XVCIA �� Trench Fee............................... $ <br /> �-NAA Sewer Tap Deposit.................... $ <br /> ' TOTAL DEPOSIT.........$ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> t)Z4 Cos s-k-c�' (I <br /> Show sketch above or refer to drawing submitted - <br /> C <br /> IMPORTANT- Applicant hereby agrees to comply withal[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 indemnity 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 of insurance shall be submitted to the City Risk Manager prior to issuance <br /> of this permit. <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,AND 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 INVALIDANDTHE 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 t <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PER BEF <br /> 9ORE NTNG. <br /> Si ned:'bA +n� Phone.- 5 T1�ZZ? <br /> ,.,. <br /> ist-Permittee(white) 2nd-Inspection(pink) 3rd-File(yellow) 41h-Finance(white) <br /> 7 <br />