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V� <br /> ' - gip ■ ` v Cri-t.31.�...O. f St_.OTck.._t�a�nP_..W.. -Perm it <br /> (209) 937-8901 <br /> p. 1 <br /> CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT,i 69018 <br /> n� APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's N me� �Z.CO R[-11) SU IC Date 01i_2 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (OwnerlContracto Subject to the General Provisions and Special Conditions, <br /> Address Q, Phone9719-- 7"7-gV11 and all work must conform to the project's approved Storm <br /> City. �'�%Q%, _ State . _Zip _IL­I5- _ Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. d y, - of the City of Stockton Storm Water Pollution Prevention <br /> Maintenance Staff Guide,whichever'larapplicable. <br /> Owner/Contractor Address V 2 S - dux �y I <br /> Estimated Starting Date Z�i f VIA I Completion Date_ VC t 10ZI �I Permit Expiration Date <br /> (or We) hereby apply for an Encroachment Permit to carry out the following works0-1A. ! �-{ U n <br /> u, e.�-_ i e esu l v�,2C2el <br /> ATTENTION:ApplicanVContractor-you are responsible to 1 Z3 <br /> replace all broken,damaged,andlor raised sidewalk,curb and PERMIT FEE ..'.................... $ <br /> gutter from score mark to score mark adjacent to the parcel; <br /> remove USA markings upon completion of the permitted work. Addition II Footage Fee ......... $ <br /> The above named appncant hereby requests permisskon to: <br /> Trench Cut Fee......................$ <br /> Sewer Tap Deposit ..............�...$ <br /> II i oa <br /> (TOTAL DEPOSIT ...... $ <br /> �C <br /> � o(•,�cLtb�le � d c�_f Z W <br /> Brldittgl Permit No. <br /> Improvement Pilan No. <br /> i <br /> Supplemental Conditions: <br /> PERMIT NOT VAIJD WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (249) 937-M TO REQUEST A CONTR03I, <br /> NbMBER NO LESS THAN 24 HOURS, BUT NC'T ird <br /> EXCESS OF 72 HOURS PRIOR TO START OF WiDcti(C. <br /> Show sketch stove or refer to drawlnp submitted CONTROL _ <br /> IMPORTANT: Applicant hereby agrees to comply with ail 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 this1permit. 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 /> PERMITTEE SHALL CALL(209)937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS,PRIOR <br /> TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENtIFIED ON THE REVERSE SIDE OF THIS PERMIT. IF <br /> WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL BECOME <br /> INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER. (FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION <br /> IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEEF6T(209)937-8441 FOR SPECIFIC <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Signed: I Phone: r� Z <br /> ,,s� ^-- +-� ••.ti+-. 9nd—Incnnrtinn fnink] 3rd-Filet(yellow) 4th-Finance(white) <br />