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• CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT /r f ? 9 4 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name FRISK l�O?_,, -L' Date APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) 5 r, o <br /> Address 0 ySD-CL [ Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City(`7lA-V_.l,� State_Zip OL ,I 2 Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, eta _,alD2"i�-� �, I'V1F•Y tC of the Ci of Stockton Storm Water Pollution Prevention <br /> Main cerSt Guide, which v 's applicable. <br /> ST Qf(kif, .ST17C�TDn1. f NS t C>C w ,_ fit_. <br /> Owner/Contractor Address By ate <br /> Estimated Starting Date �0 Completion Date [ Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> so¢,L r-�Sb w I Ute. IS t N S 1r e r-> -1-2t <br /> 1 1.-t T-Y� r D(7— wArL­f l_ t P,-6 <br /> U - Zo 21 . FLr .A-SF C��L _ I•,�o�ww n J� <br /> c �JJ A--T— Z a F 17 �� tJ Ccs�S`cA c a2 Lc_Pc 9,�� T7t1 5, <br /> SJgI�t tT7—�..C� �PP2c5 tt�D $� J ' SAc-�Jz CJJr, 1 �ai <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. Additional Footage Fee.......... $ "�— <br /> The above named applicant hereby requests permission to <br /> Sewer Tap Deposit.................. $ <br /> 2 / DO <br /> TOTAL DEPOSIT ...... $ 3J / <br /> ` Z-Tc), Building Permit No. <br /> Improvement Plan No. <br /> C ( G Supplemental Conditions: <br /> 5�- <br /> CON 70L NUMBER. <br /> CALL (209) 937-&SETH TOREQOEST A CONTROL <br /> l NU913ER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> Show sketch above or refer to drawing submitted CcNTP%C —_a •..Q—_1 v O—L_ <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-� -•---� Phon(�Q ©� SL( <br /> 1st-permittee(white) 2nd-Inspection(pink) 31d-File(yellow) 4h`-Finance(white) <br />