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CITY OF STOCKTON '^ �p� 'D� 7 1 1 7 3 <br /> .,UBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY u/J J 3ZG <br /> Applicant's Name G�;�,u�fy= CohsH/ tw Date 7-12-07 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> Address 1281 F. 1M.4y1c/ A,- Swr&joPhone (SPY)l .�6�1-1.535 Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City Fre-,~ State <f-4 Zip 113 7A D Water Pollution Prevention Plan or the most current version <br /> 1 of the City of Stockton Storm Water Pollution Prevention <br /> A�Location of <br /> Proposed Work, etc. T„�.�,nec ,u E Poi 4. t a> Mainten ;ceStafft Guide,whichev r is applicable. <br /> Owner/Contractor Address 7� .90 etbov e- By Date <br /> Estimated Starting Date 7-2)-07 Completion Date �`l`'/-d7 Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: ksr7r�� four YwrJvlr�rri lvG��s J� <br /> _ G <br /> -5ai•� <br /> ATTENTION:Applicant/Contractor-you are responsible !E C0 <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ - 9 <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 /> �G �oGCn ed Aula TOTAL DEPOSIT ...... $&At3 3 <br /> Permit No. e527- 2S W 7 1/✓ <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT HOT VAUD WTHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 937-836rr TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> Show sketch above or refer to drawing submitted C0y4 R0 ____ <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 /> t <br /> Signed: /, Phone: <br /> 151-Permittee (white) 2nd-Inspection (pink) 3rd-File (yellow) 4th -Finance (white) <br />