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CITY OF STCKTON <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY �3 <br /> Applicant's Name M.° 1'IPP j rA11iVlYhtilNetl;ri_11rYDate V APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> Address ES'5 1 SShgLU Rotid Phone (289)q(,-1-I60(a Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City duet;kun State _Zip 95a)S Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. Nd;thInof the City of Stockton Storm Water Pollution Prevention <br /> Ct ian Paw Maintena ce Staff Guide,whichever is applicable. <br /> sidewa-ilk a 111PPIHA1n SW*4 LNpC 0 avneV of Mladt A nWjje4r 31) <br /> Owner/Contractor Address _�I. t 4InRk� By x� // �// Date �I�� <br /> Estimated Starting Datea ^ r ^ !'12 6 Completion Date Permit Expiration Date > "/- /O <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: fdVl9ry_.e nne 2'­111 hnviv�a -M <br /> i P <br /> Work is W- ih eyshvid4'r� tea(_ t (Zj�g> I) nrn�ec} jh.yy 1 W 71& U)atk <br /> ATTENTION:Applicant/Contractor-you are responsible to �� <br /> replace all broken, damaged,and/or raised sidewalk,curb and PERMIT FEE.............. $ <br /> gutter from score mark to score mark adjacent to the parcel; 3 <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $ 3c7 <br /> The above named applleant hereby requests permission to: n <br /> Sewer Tap Deposit.................. $ r0 <br /> TOTAL DEPOSIT ...... $ Z <br /> 'lease "qeg a4taoher) dl-etluilly <br /> �) Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT NOT VAUD WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 937-8386 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 rater to drawing submitted CONTROL <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 /> n `` <br /> Signed: I Phone:�//f'Tt? ``W(�- I W <br /> lot-Permittee(white) 2nd-Inspectlon(pink) 311- Ile(yellow) 4m-Finance(white) <br />