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,i <br /> �CITY,OF STOCKTON <br /> kDEPARTMENT <br /> 'j — 75335 <br /> .. 'A°P P L - <br /> ICATION <br /> FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> I Applicant's Name - smwirac Cr,.l _, i ce_ Date <br /> r7 `k <br /> (Owner/Contractor) S�zVic J Ir iZ-t*ic: APPROVED BY TH iRECTOR <br /> r. <br /> Address o1 �i�.l�i� ted A {_uo Phone`(4�6 -j3 ,E p zL� Subject to the'Generalii Provisions and Special Conditions, <br /> and ail work must conform to the project's approved Storm <br /> City_2��, ��9Zo :�,State ' i!_ Water Pollution Prevention Pian or the most current version <br /> �1+--. .. ���Zip— 337—• .x. <br /> Location of Proposed Work, etc: of the City of Stockton Storm Water.Pollution Prevention <br /> CC , Q�r,Z 4A ''i � I Maintenance Staff Guide, whichever is-applicable. <br /> STDC'.L`,'-Ty J, (A, S, G �Tr�'T[ Nl e �i7L } <br /> Owner/Contractor Address yr nµ . <br /> BY � � 'Date <br /> Estimated StartingC <br /> Date: ' f Completion Date Permit Expiration Date.t:; <br /> r y'! <br /> I (or..We) hereby apply for an Encroachment Permit to carryout the following work: <br /> Ch .n! OF , _WeLL_; . � � � ch <br /> � <br /> r., <br /> ATTENTION: Applicant/Contractor;' you are responsible to <br /> replace all broken, damaged, and/or:raised sidewalk, curb and ` 'PERMIT-FEE........ $ G fl -ES, H i <br /> gutter from score mark to score mark adjacent to the parcel; � <br /> remove USA markings upon completi . Additional Footage Fee <br /> on of the permitted work . .-.....' z <br /> . $ <br /> PP Y <br /> re u s s rmi sio to: <br /> (� <br /> The above named a licant hereb <br /> t Sewer Tap Deposit.......t $ . <br /> f y <br /> TOTAL DEPOSIT .:... : $ <br /> Building Permit No � T- <br /> '' 'Improvement Plan No "sem <br /> . <br /> M�✓'� J Supplemental Conditions: <br /> _ <br /> S me a1 Coons <br /> i <br /> U0 W OUT <br /> r;, lj 97g TQ REQUEST AY CONTROL;. r <br /> I EXC SS OF 72 HOUR PRIOR TTHM 24 O START OF RS, BUT WOW <br /> �T <br /> Coh TROs <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 applicablecity ordinances, resolutions, <br /> Standards and Specifications currently in effect, and to pay to theiQty 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 ofi: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.01 <br /> IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROLNUMBER THE CONTROL NUMBER WILL <br /> BECOME INVALID AND THE 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(2D9).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 SIGNING." <br /> Signed Phone: I Z l� <br /> 1st-Permittee (white) 2q11-Inspection (pink) "'311'-File (yel0w' ) 4th-Finance (white) <br />