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ENCROACHMENT PERMIT Permit Number <br /> CITY OF 5PI(n - 17 <br /> STOCKTON ON PUBLIC RIGHT-OF-WAY <br /> 471%�' �'qi>�l �Aa.J kI,) <br /> Applicant: /tL/iPWI.f y.f. //i✓G, Date: 7-M-1/ ' J APPROVED: BY,THE DEPARTMENT DIRECTOR <br /> Z Subject to the General Provisions and Special Conditions,and all work mus <br /> Address: /o/ /iY!lill//� t�//7y� Goin✓T i SDJ/Tf 7�r7 conform to the project's approved Storm Water Pollution Prevention Plan o <br /> N .he most current version of the City of Stockton Storm Water <br /> pollution Prevention Maintenance Staff Guide,whichever is applicable. <br /> City: /Q111P!/1Z/e '/,/ State: ZIP: ff�07��_ Q <br /> 9/6. A6S x/77 LL By: Q�1� hQ Date: V I'DAP <br /> t(/ <br /> Phone: E-mail:�,O M/S. I Z Gd�Slnlgr(!/I�A�/S L <br /> �MlAssociated Permit(s): Expiration: <br /> WORK LOCATION: /jAy !L/ j ,r.« , <br /> ' ��* y�a VSD iia i�TA <br /> Start Date: (per //-- p 9-/1! �bLlt9 .ir: <br /> q- /(� Completion Date: a +s 3�e <br /> CALL (20), ) 937-5MA TO REQUEST A CaiT <br /> ROL <br /> ATTENTION:Applicant/Contractor-you are responsible to replace all broken,damaged, NUMBER f4O LESS THAN 24 i'k:�S, <br /> and/or raised sidewalk,curb and gutter from score mark to score mark adjacent to the EXCESS Or 72 HOUr'�S I BUT MOT 11 <br /> "� PRIOR TO START OF <br /> parcel;remove USA markings upon completion of the permitted work. eQNWOM <br /> I(or we)hereby apply for an Encroachment Permit to carry out the following work: <br /> f}•Ctl fji..xW A!D�✓frJ/Li/tnl !�'C// A//T/it.✓ /�9,e/7�.vr1 G✓4i LGI✓TC/ S'l�C�r�SPa�i r� �9+�1r✓k`. �'tJ Go�.l/ .s�//rJ . <br /> 41.0-7r,710/-Y k.P111 MUA-1-9, Mw-/O,MWI/ , 6 - . 9�✓b S-/o 6✓i �1 ✓r✓✓�✓`� �l/9/�J �fiE yro,, <br /> /1PrrJ/J/N/NyI Wf/� 6✓7>6`i�✓ �'l� /L/ ! o� w.ortJ w//,/ 9-3 /o"-r4l 6a -w M9 /0 7aty <br /> a +. <br /> w!%/ ;'h'*- `'JY �/t/r✓eb y f�✓r/''��u.w ��,T� GIN..✓syG<f�G�.'�9-�',�j . <br /> �// /!i h/V• <br /> Show sketch or refer to attached Drawing Official Use Only <br /> Base Permit Fee $ �Zj, 00 <br /> Additional Footage Fee $ <br /> M i Sc.7 Fat $ 3-I. 23 <br /> Misc.• $ 'JD,�✓S <br /> !, Misc. $ <br /> 2 Total $ ,���j•(v <br /> #eL4 ITS/0w"00, 41,932-) Special Conditions: <br /> ` w * Za9 - 1 —0399 -fir c,�► 1 <br /> n VWj�,e' <br /> Call. Twsn11L EKkK <br /> a� Zoq- 63� - IZ82 <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit, as well as all applicable city ordinances, resolutions, Standards and <br /> 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 <br /> requirements. Failure to comply will be cause for revocation of this permit. Applicant agrees to indemnify and hold the City harmless against any and <br /> 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 <br /> performed under this permit.A certificate of insurance shall be on file with the City Risk Manager prior to issuance of this permit. <br /> IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE <br /> OF A CONTROL NUMBER, THE CONTROL NUMBER WILL BECOME INVALID <br /> AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER. PRIOR TO /, <br /> ANY.REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS Sign / <br /> PERMIT,PERMITTEE SHA L CALL INSPEC!IONS AT(209, 937.8381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE � <br /> SIGNING. Print <br />