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4 ITY OF STOCKTON ����jlo� <br /> Y y W4G�RKS DEPARTMENT 57 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> 13j <br /> Applicant's Name AEC,� 10C Date APPROVED: BY THE KS DIRECTOR <br /> (Owner/Contractor) 2, ) <br /> Address I/1]�tjne. Pte'mQlw- Phone�-�-$7��- Subject to the General Provisions and Special Conditions, <br /> ,�n and all work must conform to the project's approved Storm <br /> City /V I ooks+-C) State CA Zip 5,351 Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, eta ��- �' of the City of Stockton Storm Water Pollution Prevention <br /> Jn 1 .l / Maintena Staff Guide,whichever is applicable. <br /> `31-" , 2201 IV 1" a ncl, I-G n-e, S iyG�lY���JF <br /> Owner/Contractor Address SAi-P Qt r� Ayf -ey Date /✓ �� <br /> Estimated Starting Date IO- ✓� Completion Date_8-/s-I� Permit Expiration Date <br /> I (or We) hereby apply for annEncroachment Permit ttoo ca out the ff 1lowing work: 2 r^ <br /> t I04 Z011 <br /> raWARANMENIAI HEMM4 <br /> PERMIT/SERVICES <br /> ATTENTION:Applicant/Contractor-you are responsible toG e <br /> replace all broken, damaged,and/or raised sidewalk, curb and PERMIT FEE...........:............... $- 3 <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.......... $ 37 7 <br /> The above named applicant hereby requests permission to: <br /> Sewer Tap Deposit......:..........: $ (� <br /> TOTAL DEPOSIT ...... $ <br /> Building Permit No. <br /> Improvement Plan No. f <br /> Supplemental Conditions: <br /> I,ERMIT NOT VAUD WITHOUT E A, <br /> CONTROL NUMBER. <br /> (ALL (209) 937-M TO REQUEST A CONTRCT <br /> HUMBER NO LESS THAN 24 HOURS, BUT NOT <br /> EXCESS OF 72 HOURS PRIOR TO START OF WOP! <br /> CONTROL - I <br /> Show sketch above or refer to drawing submitted <br /> I <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 /> . .. - Signe --c-,. Phone: <br /> 1s'-Permittee (white) - _ 2nd-Inspection (pink) 3rd-File (yellow) 41h -Finance (white) <br />