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a <br /> CITY OF STOCKTON <br /> PUBLIC WORKS'DEPARTMENT 4 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> li <br /> Applicant's Name M 5Va ) _ J&tOr`'Date I1 [t Q APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) , <br /> Address r SkW0Phone�r- 19(- . Subject to the General Provisions and Special Conditions, <br /> m and all work must conform'to the project's approved Storm <br /> City � a t9t State tA Zip 9560 Water.Pollution.Prevention Plan or the most current version <br /> 1. of the City of Stockton Storm Water Pollution'Prevention <br /> Location of Proposed Work; etc. / Maintenance Staff Guide, whichever is applicable. <br /> a� J' (IV ID.44 ►�ori� n1la -SIA off'4�1 M41 <br /> /r! <br /> Owner/ContractorRddress By Date <br /> Estimated Starting Date Completion Date la: Permit Expiration Date — <br /> . ___— .-��-_____uinuuum nm�rn�nuinnr�i�unruuirn�nmir�rn <br /> I (or We) hereby apply for an Encro hment P mit to carry out the following work: S�To[r D7ED� <br /> MUI <br /> AT ION:Ap ,l cnContractor-you are responsible to �. <br /> pp <br /> replacedamaged, and/or 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. Additional Footage Fee .......... $ <br /> The above named applicant hereby requests permission to: <br />'I Sewer Tap Deposit.................. $ <br /> AA"_ek. TOTAL DEPOSIT ...... $ <br /> I <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> FERM i NOT VALID WITHOUT A <br /> CONTROL NUMBER, <br /> ' CALL (209) 9374M TO REQUEST A CONTROL. . <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT ii, <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK, j <br /> Show sketch above or refer to drawing submitted 5:CONTROL# -'- <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 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 /> 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 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 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 /> f <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT SEFORE SIGNING. <br /> Signed: Phone: 42. <br /> 151 ❑.,:.-.;�k4nn li:ni:Rn\ 'Ind 1Fih:+i:i+4in Fi f: i' L\ 9rd Cil, 1-11...11 Alh moi----- <br />