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%olk <br /> IV <br /> v <br /> CITY OF STOCKTON 73851 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name <br /> ��{ra,� t Date �'� 0 � APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) 5 lC; Z Subject to the General Provisions and Special Conditions, <br /> Address 333+ �Yr�7vh �� � br. S ,ik�Phone 3v a and all work must conform to the project's approved Storm <br /> y �4 ��WK-State CA Zip Ma I- Water Pollution Prevention Plan or the most current version <br /> Cit ii of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc.S'A W a/5 N� ���� Maintenance Staff Guide, whichever is applicable. <br /> Owner/Contractor Address � By Date //-3/- // <br /> Estimated Starting Date ' ,vim 01, Completion Date /at" Mao d12c I I Permit Expiration Date <br /> ILI <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work I kvlElA ��%4 Si <br /> dava <br /> Sfic �r f�tn <br /> JaA4AYYU4Vlr01Ws r ,JC <br /> G vi� 596 �� hL• e ��� <br /> ATTENTION:Applicant/Contractor—you are responsible to I o <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FFI= $ <br /> gutter from score mark to score mark adjacent to the parcel; �— 37 <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee .......... $ <br /> The above named applicant hereby requests permission to: <br /> L C <br /> Sewer Tap Deposit.................. $ <br /> TOTAL DEPOSIT ...... $ <br /> vcr,A6/c 0p'��2�.✓ <br /> +k iHft17 Permit No. Z� <br /> Improvement Plan No. <br /> Pe Supplemental Conditions: <br /> CONTROL NUUBER. <br /> CALL (209) 937-M TO REQUEST A Ca)TROL <br /> NUMBER NO LESS TKAN 24 FOURS, BUT NOT I. <br /> EXCESS OF 72 HOURS PRIOR TO START OF�VORI� <br /> Show sketch above or refer to drawing submitted C °i OW <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 /> e--,_' <br /> Signed: Phone:-) 1 <br /> W <br /> 1S' -Permittee (white) 211 -Inspection (bink) ,31d-FIIP. (va.11ow) doh_Finanrn (,n,hit.l <br />