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CITY OF STOCKTON 68184 <br /> PUBLIC WORKS DEPARTMENT <br /> AAM5 APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Xfic df nt e j��Y`°h , ��r'��r "•�.1��,,�i��. Date -'l-C•'7 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> Subject to the General Provisions and Special Conditions,and all <br /> Address $";"� (Z(nc - Phone qk co- LQ work must conform to the project's approved Storm Water Pollution <br /> Ciry State r/� Zp ;215Prevention Plan or the City of Stockton Storm Water Pollution <br /> Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc. Z 22�k9 ) en 'e'A ciL_ <br /> Owner/G-ntractw Address 911 qt - Qe �trc�4�-n �j•� By Date l - <br /> Estimating Starting Date ' �-I - G-7 Completion Date L.•-1'4 -,,7 Permit Expiration Date_7- ill --c <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work:—itiL <br /> a s _ Cce'- c � .n _ S.�P....r.��<` �r�1. en _k� 5.-.,1� Siosr_ .+.1• <br /> All a,i4L <br /> The above named applianl hereby requests permission to. <br /> PERMIT FEE............................$ <br /> SEE- S r k.vw p ,,,/ ���y� �,�� ���` Additional Footage Fee............ $ 7y�� <br /> fTrench Fee............................... $ C/ _ <br /> Sewer Tap Deposit.................... $ — <br /> TOTAL DEPOSIT.........$ <br /> Building Permit No. ____ <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> '3ER. IIT NOT VALIL kvITHOLIT A <br /> CONTROL NUMBER. <br /> GAIL:- (209) 937-8366 TO REQUES i A CONTROL <br /> j !4UMI3FR (40 LESS THAN 24 HO S, BUT NOT IN <br /> r XCESS CrF 7-HOURS M,OR TO STAIIRT OF WORK, <br /> I Shan skelel above or refer fo drawing submitted <br /> IMPORTANT: Applicant hereby agrees to comply with alf 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 SHALL CALL(209)937-8366 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(209)937-8411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. if <br /> Signed:�1.oW <br /> Phone: C16 t L7- z ec &- <br /> 1 st-Permittee(while) �(pinx) 3rd-File(ysltow) 4th-Finance(white) <br />