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�I S CITY OF STOCKTON r PUBLIC WORKS DEPARTMENT APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY Applicants Name �I�SSrZX 4S ltAL Data 111 '%491 APPROVED: BY THE PUBLIC WORKS DIRECTOR (Owner/Contractor) (CI �' -��- � - �Q --L Subject to the General Provisions and Special Conditions, and all Address V4 Phone work must conform to the projects approved Storm Water Pollution city State Vy Zip 535) Prevention Plan or the City of Stockton Storm Water Pollution Prevention Maintenance Staff Guide, whichever is applicable. Location of Proposed Work, etc. SChv-�cll.%k �a� 7 Owner/ Contractor Address "'t��"'""' By Date Estimating Starting Date ( 7011'.1-C31 Completion Date t% Permit Expiration Date 'z,,mla t I (or We) hereby apply for an Encroachment Permit to carry out the following work: (MkrW r Cs�Ad ya -S t1A,yx{ 4- C1. (P� The above named applicant hereby requests permission to - PERMIT FEE . ...................... ..... $ Additional Footage Fee ............ $ Trench Fee ............................... $ {- Sewer Tap Deposit"........ ...... .... $ U'l \ �UO V � 'L TOTAL DEPOSIT .....,... $ Building Permit No, Improvement Plan No, Supplemental Conditi ns: �� C� A p/ /M S- 57AA I c � t y` n file klaq � n Iv � f L�c. k d Sin lhl" Cl vi vt .S r ` 4 // "T/ C rte6 5an // Show sketch above or rater to drawing submitted 3-rA . IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit, as well as all applicable City ordinances, resolutions, Standards and Specifications currently in effect, and to pay to the City its actual cost for removal and proper replacement of any item which does not meet the above requirements. Failure to comply will be cause for revocation of permit. Applicant agrees to indemnify and hold the City harmless against any and all losses, costs, or damages resulting from injury to persons, death of person or damage to property 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 Manager prior to issuance of this permit. PERMITTEE SHALL CALL (209) 937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS, BUT NOT IN EXCESS OF 72 HOURS, PRIOR TO THE START OF WORK, AND PRIOR TO ANY REQUIRED INSPECTIONS, AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT, IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER, THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER. (FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS, PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT (209) 937-8411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) READ GENERAL PROVISIONS ON REVERSE SIDEF THIS PERFOIT BEFORE SIGNING, —7 Signed: J)� Qy*'kA�. . Phone: tsl-Permittee (white) 2nd-Inspection (pink) 3rd-File (yellow) 4th-Finance (white)