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CITY OF STOCKTON 71613 <br /> PUBLIC WORKS DEPARTMENT <br /> JIAPLICATIION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY /WApplicant's NamT21K aA/SULTAnft"SDate f 1 Z1 D APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/CoPtractor) Subject to the General Provisions and Special Conditions, <br /> Address q LL td V'1AL -J 1bj Phone Z&¢- -25 3 S and all work must conform to the project's approved Storm <br /> City �7C ESn� State�'�Zip 3O-O 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. Mainte a Staff Guide,whichever is applicable. <br /> / Q <br /> wne Contractor Address 19 At. F(UnIT G EZ ��By DateEstimated Starting Date / 2 OB Completion Date ! Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> 57-R LL -, o u E9- n/1 TD LLS' A/ER 4 <br /> E S i <br /> OLq �OnS ft Gq <br /> C4 y i CA <br /> Lots - r P rE-D <br /> P L S oAJ I f Z o. k > r�� t <br /> ATTENTION: Applicant/Contractor—you are responsible to 3 3 0 0 <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ _ <br /> gutter from score mark to score mark adjacent to the parcel; <br /> remove USA markings upon completion of the ork. Additional Footage Fee.......... $ '�— <br /> The above named applicant hereby r rmission to: �- <br /> �j Sewer Tap Deposit.................. $ <br /> J <br /> A G/� E1v �V TOTAL DEPOSIT ...... $ 3 3 66 <br /> I `r Check tF 3�` ,73 <br /> Building Permit No. ��/6 L4/ <br /> / � ���_ <br /> ( _ ( Improvement Plan No. <br /> G Vl e U Supplemental Conditions: <br /> �'r V\1 I 1 <br /> FPEFAAVIi €OE'Vr;L3sWd-OUT A <br /> C:; TL IIS. <br /> /� A;-t- (209 937-83,6561CONTROL <br /> TO REQUEST !� <br /> 4,. <br /> O NUOIBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO SI TAFt T OF WORK. <br /> CIONTROLO <br /> Show sketch above or refer to drawing submitted <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 indemnity 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:2CO4 - 5-35 <br />