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1 , <br /> N CITY OF STOCKTON e <br /> PUBLIC WORKS DEPARTMENT <br /> 72 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's- NameAVA Lgllr- r} r,_^. ' K<� noe. tz, Date APPROVED: BY THE PUBLIC WORKS. DIRECTOR <br /> (Owner/Contractor) _ <br /> i AddressL1. TNFEL1'nraAekos-(' .r,_ _ Phone' �77 -75 ''f7 Subject to the General Provisions. and:Spedal .Conditions, <br /> - and all work. must conform to the'project's-approved Storm <br /> City <y+„r_K 4 t)A state C A Zip 9 .52, e) Z Water Pollution PreventionPlanorthe most current version <br /> Location of Pro posed Work, etc. ofthe- City- of Stockton Storm Water Pollution 'Pievention <br /> p � C? F,Nnrk4: Nw�ae � .SF . , Maintena ceStaffGuide, whicheverislapplicable. <br /> i .% I. Datej <br /> Owner/Contractor Addresss�K`S" ih,,.} - ,anen, Sd. }tl^nn fir e"A 4YIt1 8Y - <br /> Estimated Starting Date ` gta � Completion Date T $ t% Permit Expiration Date IF <br /> I (or We) hereby apply for an Encroachment Permit to carryout the following Work s, � jct�' I rz to - r'i- •'xr''7C '+"O.li <br /> e) y` z tkgir - 6r, - S_e& a4- X&C �Y -Vi451.,rr r2S _ '1-Qr <br /> �, . J 1 <br /> N ('� , - ''� lti'� -� Ic M1 '7i i�+ G41- 'rin -, r 5 . b� <br /> . . il <br /> , <br /> ATTCNTIQN Applicant/Contractor you are responsible to <br /> replace all broken,;_ damaged; and/or raised sidewalk, eurb;.and - PERM_ IT FEE ...:. .:. ,..: <br /> gutterfrom scoremark-toscoremarkadjacentto theparcal <br /> remove USA markings upon completion of the permitted work. gddltlonal•. Fo9tagg Fee F . $ <br /> -. .Tn above mmed appu rhereby regr e r Peim mn la .FF L ° _ - <br /> Sewer, Tap Deposit,., . <br /> $ . - <br /> TOTAL DEPOSIT ...., '$ z e <br /> building PermltNo �f� t y F f r <br /> F )m rovembnt+Pfan Nor rJ�r t it f 4 � `, <br /> ae � � � L : t � � <� - . IPJ✓ :. p t_ r i <br /> Suppjerpgntal Conditions:. <br /> IF <br /> - Shaw.ekeloh above or reierlodrawinq e4mlllatl F - . . <br /> IMPQRTANT: Applicsnt.nerebyagrees to comply with all provisions of this permit, as well as all applicable citpordin'ances; resolutions; <br /> Standards'2nd Speoiflcatlons currently in effecf,;and to pp, ay toitFie Qi1y. ItS actual. costfor removal agdproper:replacemept;of any Item which <br /> does not meet the abdva requirements „Failure tp comply wild be caUsff:for,levocahonof tpiS;permit. Apppcent agrees.to, lndemhity and hold <br /> the City harmless against .any and all Ipsses costs or delnages resulting.frbm inturg to •persons, .dealh,ot person or damage. to property <br /> occurring ahthe site of,' or es -a result of work, to tie perfotrned ultder INls. permd . deQ)'tlflcate of in. surance shall a submittedto the. City Risk <br /> Manager prior to Issuance of thispermtt - _ .. <br /> 1F THE WORK DOES NOT COMMENCE WITHIN t2 HDURS OF:THE ISSUANCE OF A CONTROL NUMBER,.THE:GONTROC NUMBER WILL <br /> I BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CGNYRGL NDMBER. (FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDNI$ION IMPROVEMENTS,: PERMITTEE SHALL CO�ITA,G7 THEAS. IGNED CI'Il' PROJECT ENGINEER AT (209) 937.17411 FOR.SPECIFIC <br /> INSTRUCTIONS PRIOR 70 THE, BEGINNING OF ANY WQpQ pRIQR TQ.ANY REQUIRED INSPECTIONS AS IDENTIFIED ON THE REVERSE <br /> I- SIDE OF 'fHISPERMIT,' ERMfiESHALLCALIF. 937-8381 - - <br /> READ GENERAL PROVISIONS ON THE RE•VERSQ SIDE OF THIS PERMIT BEFORE SIGNINCt - - <br /> I . i 1 <br /> 1� 1 r <br /> _ SiQned: Y” ' f ." Phone <br /> is' -Permittee (white) 2nd -inspection (pink) 31d -File (yellow) 41M1 -Finance (white) <br />