Laserfiche WebLink
CITY OF STOCKTON • <br /> MPUBLIC WORKS DEPARTMENT ` i3O <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicants Name 6e4lel ' IRuarn I r L Date I ' 17- 07- APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> n Subject to the General Provisions and Special Conditions,and all <br /> Address ?i I SIO 6011d �r,,n V! r 1 7 6 Phone 916-631- 13 oD work must conform to the project's approved Storm Water Pollution <br /> 5 6.70 Prevention Plan or the City of Stockton Storm Water Pollution <br /> city Q C.rdovw State �A zip 9 Prevention MaintenMStaffde,whichever is applicable. <br /> LocationofProposedWork,etc. 308 fa CA1tf'enr+1& 51t.6GD L MtNec A�Owner/Contractor Address B DateEstimating Starting Date Z1IG Completion Date -2 2 OZ ate <br /> I (or We) hereby`apply for an Encroachment Permit to carry out the following work: tIV151 LII 6 aZo,+L Nk V <br /> "jig and orae n6a-n11'&'1in. a.L115 <br /> The above named applicant hereby requests permission to- <br /> PERMIT FEE............................$ <br /> Additional Footage Fee............ $ <br /> TrenchFee............................... $ <br /> Sewer Tap Deposit.................... $ <br /> TOTAL DEPOSIT.........$ I <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> n (fl Nn ia" doSuY46 ate nGv»,l'ffeGl u1rtL. <br /> 5� GL�C�U" Wt-u^�J roc- fi1.;5 FYo�rcb <br /> /, /�/ rt�le1d 4n <br /> Show sketch above or refer to drawing submitted �jn� t5r'l!jr� K G� �•�1in / //;�L& <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit,as well as all applicable City ordinances.resolutions,YYII I <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 indemnity 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 TH B'P RMI EFO SIGNING. <br /> Signed: Phone: (S 16) 6 31 — 130T 13 <br /> 1st-Permittee(white) 2nd-Inspection(pink) 3rd- ile(yellow) 4th-Finance(white) <br />