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CITY OF STOCKTON 71042 <br /> `..i PUBLIC WORKS DEPARTMENT `� <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> =05 <br /> Applicant's Name Date 7 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> Address //.f 7 ZU""6 f�GY� /ivC= Phone S`212?-2/ Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City State <.i Zip gSr�S-/ 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. / Ie, i.-Jr ;.4-vF� �� / Maintenance Staff Guide, whichever is applicable. <br /> 21 <br /> �11 <br /> Owner/Contractor Address By Date �� <br /> Estimated Starting Date i5 // ©' Completion Date 7va - 7 Permit Expiration Date —( <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> /n+5 �/�� r i ✓C' �QOtJ s✓.�w A 7C,-,f i k)-I e-- Il/Cr.v t; <br /> wof- <br /> ATTENTION:Applicant/Contractor—you are responsible to ems_ <br /> replace all broken, damaged, 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 /> Sewer Tap Deposit.................. $ <br /> TOTAL DEPOSIT ...... $ J J � <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> ,RV I` 'HOT VALID"WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (20'•1; 937-8366 TO REQUEST A CCWROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <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 PERMSigne,IT BEFORE SIGNING. <br /> _.�.--- Phone: <br /> 1st-Permittee (white) 2nd-Inspection(pink) 3rd-File (yellow) 41h-Finance (white) <br />