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CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT 69767 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name 4ir_ Date APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) D Subject to the General Provisions and Special Conditions, <br /> Address l//� �-0�/6 PAGII AA-- & A ITE PJ�'hone 6201� ZU t and all work must conform to the project's approved Storm <br /> City ApDgtO State 64 Zip J�7_7,5_r _ Water Pollution Prevention Plan or the most current version <br /> //II � � of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. ��Y���,lifcl�A A4P IFJV-��' Maintenance Staff Guide,whichever is applicable. <br /> :2LAO Ar C R40f- DE c�0el Sr /44 D 4660P�61 41( //-7—e Owner/Contractor Address By Dte <br /> Estimated Starting Date 110105--_ Completion Date Ds3/d SOS Permit Expiration Date <br /> (or We) hereby apply for an Encroachment Permit to carry out the following work: 3 &2146.s Q <br /> IZ E o <br /> &CIAL AWE S 0 0F ,v <br /> 1 x gag & �_ __GWD 1�/onl lqp�T —(IlVDA /y 41AR.t/11116 �Y Ali o rAlt- &� f1AJ(J <br /> D2/+tD c%VtIA ©t' �w T.�1 i gEZ'TI DTII t/F 1/i111 nA f-t/�I D Aald l DA T F, &h4T t()�*� <br /> ATTENTION:ApplicanVContractor—you are responsible to 2 n <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE............................ $ �O�V <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 /> Sewer Tap Deposit.................. $ <br /> TOTAL DEPOSIT ...... $ <br /> Building Permit No. <br /> Seg- <br /> n/� Improvement Plan No. <br /> �N�C.D��1� l V'� <br /> Supplemental Conditions: <br /> PERMIT NOT VAUD WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 9374386 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> CONTROL# s �1 JN O R <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 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 /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BE FOR SIGNING. <br /> Signed: Phone: (o2V1).54J Baal <br /> 1st-Permittee (white) 2nd-Inspection (pink) clille(yellow) 41h-Finance (white) <br />