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CITY OF STOCKTON -- <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> kner/Contractor <br /> licant's Name Ji fl/tSSo Date IM 4a o APPROVED BY THE PUBLIC WORKS DIRECTOR <br /> � f <br />' Address 401 9-1441k Ll h, s� Phane gioa 2a4-$�'� Subject to the General Provisions and Special Conditions,and all <br /> Ci .S���� _ work must conform to the prgecrs approved Storm Water Pollution <br /> State GFIC, Zip q 5-Z.� Prevention Plan or the City of Stoddon Storm Water Pollution <br /> `t N�(4-1— Prevention Maintenance Staff Guide whichever is applicable <br /> (" W� <br /> Location of Proposed Work,etc I`1 W Gv V rt r.Y ♦ S <br /> T rr S'{'✓ S <br /> Owner/Contractor Addr �f�Y <br /> ess gAr-mnAt P✓ By Data JC7 t <br /> Estimating Starting Date_ 1 t-# to I Completion Date I I t 0 1 Permit Expiration Date -'_L `d 2— <br /> I <br /> I (or We) here y apply for an Encroachnt Permit to carry out the following work. <br /> CIOfret trs� (4 Yt� ^4-CSll" �iL s --�-V VVJ le fiH-W'i <br /> The above names aPolioaffl hsraby muesrs Permission to <br /> PERMIT FEE $ f <br />' Additional Footage Fee $ <br /> Trench Fee $ <br /> Sewer Tap Deposit $ <br /> TOTAL DEPOSIT $ <br />' Building Permit No <br /> Improvement Plans No <br /> Supplemental Conditions <br /> A It %-,or k *iv (fie ;A t Ae <br /> I le <br /> r/v4.1 fCOrr PW^1� pG �rde Wcx. I I� .-5-1--t I/ 4&a leo&/,K <br /> Show sketch above or felon to drawing Ll��ini[E�rwl-e�«f{��Pr O 157 5f w/` �W A Z s <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 does <br /> not meet the above requirements Failure to comply will be cause for revocation of permit Applicant agrees to indemnify and hold the City <br /> 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 <br /> 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 <br /> of this permit <br /> PERMITTEE RMTEE SHALL CALL(209)937-6386 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS <br /> PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT IF WORK DOES NOT BEGIN 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(249)937-8411 FOR <br /> CIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK) <br /> A D GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERMIT <br /> �BEFORE SIGNING <br /> Sign, "� Phone <br /> 1st-Permittee(white) 2nd Inspection(Pink) 3rd Elle fyeu4 <br /> W) 4th-Finance(white) <br />