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O CITY OF S DEPAR N 7 2 0 9 5' PUBLIC WORKS DEPARTMENT APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY !€ i Applicant's Name RCl4C71s j��- /I'�zet'"c Date )� 1Q7 APPROVED: BY THE PUBLIC WORKS DIRECTOR Address erfContracto ) t� Subject to the General Provisions and Special Conditions, Address +4 NN S��lt /2.S' Phone��1/�} `� - ti- 1 P and all work must conform to the project's approved Storm City _ Fojif n, , State C4 Zip $- Water Pollution Prevention Plan or the most current version Location of Proposed Work, etc. ��ra,wc Ave Maintenance the City of Stockton Storm Water Pollution Prevention pp 33 /^ Maintenance Staff Guide, whichever is applicable. .S7'O C t N l CrA-. 1,1<, f Owner/Contractor Address ' ?YOI Crowe s• Vo�01 By ate Estimated Starting Date 10120/0&' Completion Date 1,12°1/t9Y Permit Expiration Date I (or We) hereby apply for an Encroachment Permit to carry �the�following lwork: / "]P'r / p 1 &r4 J,ry_,7, G M,9cX 1M.0 Al)J e.^p`./.r[7'1'4 r'4 C� 'f"L1.7`)�D toeJ m/ �,!• f ems' .Zr' . t/S/`HE _,0e"-r&4e_ Jt lS 70 Gal/J�rPT S-od rz ATTENTION:ApplicanVContractor—you are responsible to - 00 replace all broken, damaged, and/or raised sidewalk, curb and - PERMIT FEE............ .... $ gutter from score mark to score mark adjacent to the parcel; remove USA markings.upon completion of the permitted work. .Additional Footage Fee . $ _ The above nam¢d applicant hereby rogoests permission to Sewer Tap Deposit.................. $ - QQQ TOTAL DEPOSIT ...... $ 0—Al 00 Building Permit No. (� Improvement Plan No. Supplemental Conditions: PERMIT NOT VALID WITHOUT A CONTROL NUMBER. CALL (206) 937 TO REQUEST A CONTROL NUMBER NO LESS THIW 24 HOURS, WT NOT IN EXCESS OF 72 HOURS PRIOR TO START OF WORK, I � CONTROL# Show sketch above or rotor to drawing submitted IMPORTANT: Applicant hereby agrees to comply with all provisions of thispermit, as well as all applicable city ordinances, resolutions, -� Standards and Specifications currently in effect, and to pay to the City its actual cost for removal and proper replacement of any item which does not meet the above requirements. Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnify and hold the City harmless against any and all losses,costs, or damages resulting from injury to persons, death of person or damage to property 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 Manager prior to issuance of this permit. i IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER. (FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937.8411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE ! SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937.8381. READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMITBEFORE SIGNING, Signed:G/'L-' Phone: /6 7�f 7(77�J Vt-Permittee(white) 2nd -Inspection (pink) 3rd-File (yellow) 41h-Finance (white)