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CITY OF STOCKTON <br /> ° ��'i���r` PUBLIC WORKS DEPARTMENT ��� <br /> APPL"ICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY fillb'5k 05Z3/V-?" <br /> M5 �y `S4 0 5L 3/6--!"- <br /> Applicant's Name 640-16� .V" (40>1unh Date �o'I S a7 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) - r <br /> Subject to the General Provisions and Special Conditions, <br /> Address I W1 F_. ;�l , Y ..S�z : I Q ,"bhone CSSyI z6y�2S3f <br /> and all work must conform to the project's approved Storm <br /> City F/'Gf wo State A Zip 4 372 0 Water Pollution Prevention Plan or the most current version <br /> C� s� � nc�r �`y� of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. Maintenance Staff Guide,whichever is applicable. <br /> Owner/Contractor Address By e�Ve Date <br /> Estimated Starting Date 10-1&1,-0'7 Completion Date 1-7-1-c, 7 Permit Expiration Date Z7-45- <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: vet Ori t <br /> �� / Oi^l i�v+'P'P/ !�►Cl /'�P „C Yl of <br /> rc'e' <br /> AviL4jShull be l,^ Ci ^4 <br /> ✓J �E{6r> <br /> F) <br /> ATTENTION: Applicant/Contractor-you are responsible to <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ 331 <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 /> TOTAL DEPOSIT ...... $ 33 cf <br /> Pv 0A 2tc Z yfy3 <br /> SBuilding Permit No. <br /> eeJ A � Improvement Plan No. <br /> lJ Supplemental Conditions: <br /> PERMIT NOT VALID WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (209} 937-8366 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF MRI(, <br /> ',00 <br /> a R0L# <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, aild 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 /> 2_ _ <br /> Signed: Phone: 'I'J 15- <br /> 1st-Permittee (white) 2"d -Inspection (pink) 3rd-File (yellow) 4th-Finance (white) <br />