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CITY OF STOCKTON 51 oti)' <br /> PUBLIC WORKS DEPARTMENT 71612 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY 9u,0-- 67/S1,tJ <br /> Applicant's4-11J_r0M4T12,IX Cci,,IstA Anfr�ate ( f2-1 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/ ont ctor t;S3-�j <br /> Address 81 F. ,4u_t4V1.1LJ 101 Phone2 6 4—2S 3S Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City 7"le E S'do State e}- Zip 93 20 Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. of the City of Stockton Storm Water Pollution Prevention <br /> p Maintenance Staff Guide,whichever is applicable. <br /> r / <br /> Own ontractor Address ( / By Date <br /> Estimated Starting Date/ 2 08 Completion Date I II 08 Permit Expiration Date "3�S O <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> 1,67—Al-L- ti( CA/1 TO P__,Al WE L-LS 4455 2 <br /> —04 F LLZ ir(Rs7— tau"7i c�g 819 A/ x&17—E�2. SY, <br /> — Lacyl T►o c "M co-s „�► w �lc� " M U/_8 <br /> E-02- L n r'A nrZis <br /> ATTENTION:Applicant/Contractor—you are responsible to 66 <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 permitted work. Additional Footage Fee.......... $ <br /> The above named applicant hereby requests permission to <br /> Sewer Tap Deposit.................. $ <br /> f/ 2 2 Clio <br /> S4�ri1 J00"-0, /1,4 �P a� TOTAL DEPOSIT ...... $ <br /> �ev� � Checrc /30 q�3 <br /> Qa+le}" Permit No. <br /> Improvement Plan No. <br /> ee f't Supplemental Conditions: <br /> FERMF NOT VALID MTHOUT A <br /> CONTROL NUMBER. <br /> (ALL (209) 9374366 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT l <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK <br /> CONTR®L# _ <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 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 /> �ss9� <br /> Signed Phone: -2 6 4-,?Y3 5, <br /> 1st -Permittee (white) 2nd-Inspection (pink) 3rd-File (yellow) 411 -Finance (white) <br />