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C#-b -3 & y <br /> CITY OF ST,OCKTON 1082 O 8 <br /> PUBLIC WORKS DEPARTMENT <br /> M5APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name 6eeAAYiw ��tsu��arn�s Date 7-6-07 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> Address_1991 E 4H,41fJa Ove 5alfe la Phone (539) Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City State CA Zip °1.3720 Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. u j l s of the City of Stockton Storm Water Pollution Prevention <br /> _ 'r ,r' Mainte ce Staff Guide, whichever is applicable. <br /> �wC /1 t7unfi/ S� a J+.S�n /aaaKBn S� a F h<.acia 'I <br /> c - <br /> Owner/Contractor Address sA)c ,11 By Date 7 <br /> Estimated Starting Date 7- 13 -0 7 Completion Date s?-31- D 7 Permit Expiration Date -/-Or 77 <br /> I (or We) hereby apply for an Encroachment Permi t rry out the following work: �l,r ir-in 6n, >e,d bor,�,,i s <br /> ATTENTION: Applicant/Contractor-you are responsible to <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ 3 3 1 <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.................. $ <br /> See TOTAL DEPOSIT ...... $ 331 <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT NOT VAUD WITHOVT A <br /> CONTROL N1A8JR. <br /> CALL ('09) 937-8W TO REQUES)' ,', CONTROL <br /> NUMBER NO LESS TFi N 24 HOURS, BUT NOT i <br /> EXCESS OF 72 HOURS PRIOR To START OF WORK' <br /> Show sketch above or refer to drawing submitted „:�___�_,� �, ^,-�-,w.N-_-.--T."�y-,.✓ <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 /> Signed: Phone: d <br /> 151-Permittee (white) 2nd -Inspection (pink) 3r11-File(yellow) 41"-Finance (white) <br /> T -d T068-LEG ( 60Z) JiwJad-Mduoq,�{oogS ,}o RITO dZS =EO LO LT inC <br />