Laserfiche WebLink
CITY OF STOCKTO ,N � <br /> PUBLIC WORKS DEPARTMENT U 8 6 b <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> MM5 <br /> Applicant's Name A % IAhr LC) GED Fns Date 0 L p APPROVED : BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) Subject tothe General Provisions and Special Conditions, r <br /> Address 837 S_XA ,/ RraPr Phone 46 7 J O 0 and all work must conform to the project's approved Storm <br /> City S Tok 0 State C� Zip 9 SZ f 5 Water Pollution Prevention Plan or the most current version <br /> r-- of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work , etc. Re'� � G � Mainteripfute SlElff Guide, whichever is applicable . <br /> '715 N . HvnjfKr s 'Frgg j} / -7 <br /> Owner/Contractor Address 837 5N q w R D . STotKta By P� aLte Z7O7 <br /> Estimated Starting Date 030 ! / O `J Completion Date 09 I A Permit Ex ration Date —� p7 <br /> - -- - <br /> I (or We) hereby applyforan Encroachment Permit to carry out the following work: <br /> � evs T LovQI £ l}SSCODU �-t. Q,vtI n <br /> C I%Pik °� h �- — O (=• " te .F�—1 , <br /> ATTENTION : Applicant/Contractor — you are responsible to �,/ pi <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE , , . . . . . . . . . . . . . . . . . . . . . . . . . $ 7 <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 , , . . , , , , $ 'j <br /> TOTAL DEPOSIT . . , . , . $ 3Z _fu R � <br /> 5 Building Permit No . <br /> Improvement Plan No . <br /> Supplemental Conditions: <br /> PERMIT NOT VALID VATHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 937-8366 TO REQUEST A CONTROL. <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT !f <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> CONTROL#.„.. ._..t. <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. Acertificate 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 FORA NEW CONTROL NUMBER. (FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS, PERMITTEE SHALL CONTACT THEASSIGNED 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 BEFORE SIGNING. <br /> Signed : Phone: <br /> 1a' -Permittee (white) 2nd - Inspection (pink) 3rd -File (yellow) 41h -Finance (white) <br />