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67957 <br /> CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT <br /> AT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name A-( e Date NOy. �,,2003 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> R Subject to the General Provisions and Special Conditions,and all <br /> Address I 11-1 L o e- Pr. ... 1AVt✓,1, 54-C Phone 20l`'S76--X22,work must conform to the project's approved Storm Water Pollution <br /> City M OAS ILo State CA Zip ?T-35"1 Prevention Plan or the City of Stockton Storm Water Pollution <br /> c I Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc. Rn t-on 5+_'4 k 4 St lI-kc in 3 I,e/ <br /> rear (IC2 t . N4�dt �Js�, S+e)JZ--Vn, CA t— /000, f <br /> Owner/Contractor Address _111 t-o,.e_ P , Q,UQ.• 5 <br /> fin4'6.h de-S f o By Date <br /> Estimating Starting Date ///��o� C� Completion Date J1��1/Q3 Permit Expiration Date Z <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: f n S 7'-a e) G r�Und <br /> /ti f�>- ►�� d o r E Q11 n�. �t <br /> .41k (n1 C f 4-m R- 51,-k_ ►N<y D��Cr c e n [) ///Z �- f ti'/.-r <br /> The above named applicant hereby requests permission to- 0 <br /> PERMIT FEE............................$ <br /> i ' I Additional Footage Fee............ $ <br /> Trench Fee............................... $ <br /> n oU 0C- Pte-' Sewer Tap Deposit.................... $ -i!� <br /> TOTAL DEPOSIT.........$ <br /> t Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Sw G�� Cla/^2 ye� <br /> S�o�< 44^P(c t4 SCO�e Amt <br /> Show sketch above or refer to drawing submilted /4 <br /> WOO <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 does <br /> not meet the above requirements.Failure to comply will be cause for revocation of permit.Applicant agrees to indemnify and hold the City <br /> harmless against any and all losses,costs,or damages resulting from injury to persons,death of person or damage to property occurring at the site <br /> of,or as a result of,work to be performed under this permit.A certificate of insurance shall be submitted to the City Risk Manager prior to issuance <br /> of this permit. <br /> PERMITTEE SHALL L(209)937-8366 FOR NTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE S RT OF WORK, TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT.IF WOR GIN 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 <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. /Gj <br /> SigneVnd-1 ,pction <br /> Phone: <br /> 1st-Permittee(white) (pink) 3rd-File(yellow) 4th-Finance(white) <br />