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M - <br /> CITY OF STOCKTON <br /> �9 DEPARTMENT 76753 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> M15 <br /> Applicant's Name/9fi"WVJk WA1-t�f1?t 1 e_1 Date )2-3-42 �D <br /> APPROVED: BY THE DIRECTOR <br /> (Owner/Contracjtor) <br /> Address WiNAPLky� �� Phone�lt: 9��-Z/ Subject to the General Provisions and Special Conditions, <br /> t—T and all work must conform to the project's approved Storm <br /> City a wew State Zip 9576 2 Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work,etc. 3gyD �•MAtN ST, 8.�: of the City of Stockton Storm Water Pollution Prevention <br /> , <br /> / Maintenance Staff Guide,whichever is applicable. <br /> rrcut rcLT����9 [cs R�/f1l/� <br /> Qwner/Contr for <br /> Address �Dl' i'f� Sy tk t L"le V40 0 "Date <br /> Estimated Starting Date 61f f' '-' Completion Date 4"Y-7*' Permit Expiration Date s —, <br /> I (or We)hereby apply for an Encroac p/e-9 ,m�'ty�t9,cfrry out the following work: Ne pwi,S5/e7 Zre-giew �)n�� <br /> hOd(LId,tX (J� •v�3ccyv t 9 �'e!'lS l .+� Maui dt /fes a✓�rrN� l�nY�: <br /> A106 <br /> ATTENTION: <br /> �€✓OGt7�B« �F�z�YfT 96-O cj�cc�, lYlatz�8� /9�( ��S 41�c�,o.��yn :ate 329�/�- <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; <br /> remove USA markings upon completion of the permitted work. Additienal Feetage Fee7ZR.- $ 3y Z J <br /> The above named applicant hereby requests permission to: s 0 44, <br /> 5,-a at(adv a N&I (05g It A-- <br /> z� TOTAL DEPOSIT ...... $ 5_42 �c <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PffAff A <br /> CONTROL N . <br /> CALL ('209) 937-8398 TO REQUEST A COMM <br /> NUMBER NO LESS THAN 24 HOURS, BUT PHOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF VtlORK. <br /> CONTROU <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)937-8411 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 /> Signed: (�lllZ&-t�� I, er'-"4 Phone:C9 9 r'7f7;Ir <br /> `I->`ml 7_,ra,zWw0WK� e 7A <br /> 1st-Permittee(white) 2nd-Inspection(pink) 31d-File(yellow) 41h-Finance(white) <br />