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.I <br /> Il <br /> V 12 / 26 / 2001 12 : 57 209 -579 ? 25 MODESTO ATC PAGE 06 <br /> N W. . <br /> CITY OF STOCKTON AN <br /> PUBLIC WORKS DEPARTMENT V J <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT OF-WAY <br /> M5 <br /> Appplicant's Nama <br /> �Ar-s1zC 4 I� Data I t 11`t 01 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (O wrteNContractor) Subject to the General Provisions and Special Conditions, and all <br /> Address U t -:L l.r�IAAL tln,(aa Atr`W - *- ^ l^ Phone 5+- -xzl work must conform to the projects approved Storm water Pollution <br /> City ifJi _ State Vi Zjp � � Prevention Plan or the City of Stockton $form Water Pollution <br /> o� Prevention Maintenance Staff Guide, whichever is applicable. <br /> Location of Proposed Work, etc. SC.�M Jit pe" <br /> Cz <br /> Owner/ Contractor AddroSs I H PAIA' By Date /G ~ y� <br /> Estimating Staiting Date t Zb �l _ Completion Data 3ZZECRONE 1/111401 Permit Expiration Date /p r <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> The atwve mined eppliomi nafoby requeea permimwn to A <br /> PERMIT FEE .................. .......... $ <br /> Additional Footage Fee ............ $ <br /> 1 ' <br /> ,J_, L fi 1 Trench Fee .................A............. $ .. <br /> SY�1 t�vS �1tl�M�1 <br /> Sewer Tap DepoelL. ...... ..... ...... . $ <br /> U4 rwqx " L TOTAL DEPOSIT .. ......, III <br /> Building Permit No. <br /> Improvement Plan No- <br /> Supplemental <br /> Supplemental Condki a: } 'e e A ft, <br /> e /AM 1S ,f'41^ 1 .n .f e, l h <br /> 'I"++1"P kla � 4.err • Ornk d" .So. n <br /> YCA yt Wif[ r <br /> i <br /> X411 'Tr rc 64 #4 #1A Stier! eonFvrru <br /> snow skerah ebow or Few to crewing aubmmee f e* t' <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit, as well mall applicable City ordinaries$, resolutions, <br /> Standards end Specifications currently In effect, and to pay to the City Its actual cost for removal and proper replacement of any Itom which does <br /> not most 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 alta <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 CALL (209) 937.8308 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS, BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE START OF WORK, AND PRIOR TO ANY REQUIRED INSPECTIONS, AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT. IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OFA 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 qF THIS PERMIT BEFORE SIGNING. <br /> 91 nod; � Y �7 � 5 rte <br /> 9 Phone: ` � Z �Z <br /> r:./ Vis I <br /> 1stops"Itlee (white) 2nd-inspsglon (pink) ori-File (yellow) 4th-Finance (wttlle) <br />