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CITY OF STOCKTON <br /> S PUBLIC WORKS DEPARTMENT 719 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY S/— Oslo�� <br /> Applicant's NameAilotej Glcc tnvirotimeri6i Date 3.1 g h APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> Address� Shaw Road Phone Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City S*I(+Vn State A Zip 9 5215 Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. W f}I,i h G-4u ,•F $+od(:b P1 RD M the City ngwEate <br /> Stockton Storm Water Pollution Prevention <br /> Mar is applicable. <br /> sde1WA�k t( (o01 Maty11tstreef Oyeceneed("/yxirt4ne 6tn) <br /> Owner/Contractor Address C17U of S61*-- Dii By <br /> Estimated Starting Date 3- 1D-D9 Completion Date (0-10-0`j Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: /4,,I`v in n-a o2 3 c7) <br /> a rP e( 5o16i &r roi(e&;p, rDH ct WAk,( and szeda l s. Ado welik <br /> oyt 11 l,t It's-W14A.It's—W14wee i f Ai`n C2n% 15 SSG✓ <br /> ATTENTION: Applicant/Contractor-you are responsible to C (..� ®e <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ SO / <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 a plicant hereby requests permission to: <br /> tQ A�ac�ed d�w'� Sewer Tap Deposit.................. $ —v � <br /> p� sr; S TOTAL DEPOSIT ...... $ <br /> R; will Qfojeck',Mv Row Ov"f4k° <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT NOT VALID WITHOUT A <br /> CONTROL NUMBER, <br /> CALL (209) 937.8388 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 /> CONTROL# <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, 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)937.8911 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)) SIIIGNING. -1 <br /> Signed: dL__ ila Phone: ul-104 <br /> ,.....--I;,.., hri-L\ q1d _Pilo (voilnw) 41h-Finance (white) <br />