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CITY OF STOCKTON 6 g 7A 7 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> AM5 <br /> Applicant's Name Date APPROVED : BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/G' cta <br /> Address -? IILo-'V &' 17f Phone -.�l'% 1.% )—/Udt �' Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City State 4sF) Zip i f 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. _1'11.> (>lDC.`C cl ,Ahr A, Maintenance Staff Guide, whichever is applicable. <br /> Owner/Contractor Address 6? y ellete4 _ BYE <br /> Estimated Starting Date /0' ZS-OS Completion Date / Z — /—OS" Permit Expiration Date / 2 —/f-O�5 <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: J n s' Lzc ) / nr / ill [ff gk teT it_l <br /> r //f <br /> iJ!') 1�C! S"/C- L'Ct.G ,/- 5L.)� <br /> ;C'i1 /%1% Gi lP1ry 1V l7vc, 2r ` 7i={ tT %cti°e1 ( 'T (' .� cctr. vn -< ilf Ru <br /> 0.( . & C C QS 206 Al IV In L i( <br /> ATTENTION : ApplieanVContraetor — you are responsible to O � <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Z <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 Depostt . . . . . . . . . . . . . . . . . . $ <br /> s ) TOTAL DEPOSIT . . . . . . $ <br /> ltiC) � / ' <br /> w <br /> Permit No . <br /> Improvement Plan No . <br /> Supplemental Conditions; tis y0 <br /> PERM`!' NOT VALID WITHOUT A <br /> COBE ZOL NOMAR <br /> CALL. (209) W7416568 TO REOIJES'tA CONTI ROL <br /> NUMDER NO LESS TION 24 HOURS, BUT NOT IN <br /> OXCESS}� OF T2 HOURS PRIOR TO START OF VdOXK* <br /> Show sketch above or refer to drawing submitted d•e'^" � I ry��:TE^ h <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 BEFORE SIGNING, <br /> Signedl,^0 Phone: -209467 — I0CJfP <br /> 151 -Permittee (white) 2nd - Inspection ( pink) 3`d -File (yellow) 4" -Finance (white) <br />