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Y4� CJTY OF STOCKTON . 75305 <br /> -' DEPARTMENT ;r <br /> I� ENCROACHMENT ON PUBLIC RIGHT-OF-W <br /> APPLICATION FOR <br /> TH <br /> I ECTOR <br /> Applicant's Name <br /> �'LS Date J�L APPROVED: 13Y' <br /> (Owner-/Contractor) Subject to the General Provisions and Special Conditions, <br /> Address Phone and all work must conform to the project's approved Storm <br /> /� Water' Pollution Prevention Plan or the most current version <br /> City State r� Zip "I of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. St0 At.K. +4NA STR�— Maintenanc taff Guide, whichever is applicable. <br /> By -�l Zl <br /> ate <br /> Owner/Contractor Address <br /> Com letion Date 20I �l Per <br /> Expiration Date <br /> Estimated Starting Data I p } <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> 1 <br /> LA _N - <br /> 1, <br /> s t5 <br /> ATTENTION:ApplicaAContractor—you are responsible to <br /> replace <br /> frolm scorenmark to and/or raised sidewa <br /> adjacent to the parcel;and PERMIT FEEee T....................... $ <br /> � 3 <br /> i gun ee.......... $ <br /> remove USA markings upon completion of the permitted work. I � <br /> The above named applicant hereby requests permission to: -se $ C! <br /> FA <br /> TOTAL DEPOSIT ...... s,-zZ=D MW- 13 00 A-VIA0461- 'i <br /> Building Permit!No. <br /> Improvelilent Plan No. <br /> Supplemental Conditions: <br /> N U98.1 <br /> A'�t izut i A37-5366 TO REQuEST A CONTROL � <br /> is IWYER `:, ilss THVN 24 HOURS, WT NOT IN <br /> �,z E-;F.'72.1 HOUR1 PRIOR TO START OF WDK <br /> -.110141 NIOLS; <br /> Show sketch above or refer to drawing submitted <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 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 c ertifical 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 A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> 1 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 BEFORE iSIGNING. <br /> Signed: <br /> Phone: _�E�II�.�B�-�" I <br /> 9 <br /> I� <br /> ��rd-Pilo'rvannwl 4" -Finance(white) <br />