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�POFCKTON <br /> EPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> cze?112 <br /> Applicant's Name S7ANTE76 COMS(IoLfig6 ' Date 10 26 .li APPROVED: BY THE KS DIRECTOR <br /> (Owner/Contractor) Subject to the General Provisions and Special Conditions, <br /> Address '3617 c46cp F Ro . Sunt IOC Phone 616)rr6I tl6400 and all work must conform to the project's approved Storm <br /> City j'CANc4tt C-1APoVA State CA Zip 95670 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: yiowacgitsG QESTt~yc-1104 Maintenance tall Guide, whichever is applicable. <br /> ffi+l we57 ltortoltAFR LH AT I~eLLey pR <br /> Owner/Contractor Address SAMt. & By �'� Date <br /> Estimated Starting Date NOV 7 1T60 Completion Date PM 31 2nti Permit Expiration Date 7A*t <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: Hoiji-razitJ . wAutL- Ve51K iLo 19V <br /> r WA-I-A"eM Ont A1 KE-Lu��Y DR TcT/rt- ' "EEE' CMtJ—G MIJ t.a—I t <br /> ATTENTION:Applicant/Contractor' you are responsible to <br /> replace broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ <br /> gutter from scorelto score mark adjacent to the parcel; 73 <br /> remove USA markings.'upon completion of the permitted work. Additional Footage Fee........... $ <br /> The above named applicant hereby requests permission to; `/47 W G <br />. Sewer Tap Deposit.................. $ l.V . <br /> vim. P�5 T�vGTraN tai Vu 7 Kf5mt-let" U4 J 4 <br /> CSS AY7AGiiCD� <br /> TOTAL DEPOSIT ...... $ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> is kk t kCif VAUD VfIT!' UT A <br /> ITROL NUMBER. <br /> r:11 (�9) 9374LW TO REGMST A CWTROL <br /> UMBER NO LESS THMI 24 HOU & BUT NOT M <br /> CESS OF 72 HOURS PRIOR M SMIWII M' <br /> ONTR�E�L <br />` Show sketch above or refer to drawing submitted rt <br /> i <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 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 dsses, 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 PERMITTEE SHALL CALL FOR ANEW 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 BEFORE SIGNING. <br /> Signed: Phone: <br /> I o/2C/ti <br />