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S CITY OF STOCKTON 7 6 5 6 6 <br /> C6 PUBtICWORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> CI) <br /> Applicant's Name -APLA pv�p Date 5 APPROVED: BY THE PHBtiCWORKS DIRECTOR <br /> (Owner/Contractor) t��Df <br /> f, Subject to the General Provisions and Special Conditions, <br /> Address I V I PQ IDF PA <br /> and all work must conform to the project's approved Storm <br /> City /L( State QPhone '.Zip Jr�15 Water Pollution Prevention Plan or the most current versionof the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. � 0-- [�(C,{i�,t �_ M <br /> ( <br /> Maintenance Staff Guide, whichever is applicable- <br /> WW-Y- Ass lu=AM-0144?0rsr NIS AJ& <br /> Owner/Contractor Address By Date <br /> Estimated Starting Date qu — Completion Date ) Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: 1T-.6TQ Jl-U IG_f4r= LA TSI t S <br /> W <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 apPgcant hereby requests permission to <br /> Sewer Tap Deposit.................. $ <br /> i, (��/ TOTAL DEPOSIT ...... $ <br /> ✓"`� apt \\TTS "OD Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERr4j1'I NU I VALID vitfiHOUT A <br /> CONTROL "NUMBER. <br /> CAI!. (209) 937-R366 TO REQUEST A CONTROL <br /> NWREF NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCEL:;OF 72 HOURS FZIOR'i 0 START OF WORK, <br /> C'NTROL.# ___ <br /> Show sketch above of 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 indemnity 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 NO r 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 REOUIRED 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 /> Iyn�'/JI �.,� <br /> Signed: 1 1 1 Phone: �N_G5 <br /> 1s'-Permittee(white) 2nd-Inspection (pink) To-File(yellow) 4'h -Finance (white) <br />