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CITY OF STOCKTON 72957 ' PUBLIC WORKS DEPARTMENT APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY ge.^ Ew191o1mt4}at Applicant's Name Aa A•e L DateSlto)oa APPROVED: BY THE PUBLIC WORKS DIRECTOR ' (Owner/Contractor)` A.da�r36St Subject to the General Provisions and Special Conditions, Address 611\611\ Bollr^ r +&only^ rd• Phone qtr. 5yi-L349 and all work must conform to the project's approved Storm City C6,4 rLa...e. State 6^ Zip 9 3 Water Pollution Prevention Plan or the most current version ' of the City of Stockton Storm Water Pollution Prevention Location of Proposed Work,etc. A1oNb.mar )ollt e.. Maintenance Staff Guide,whichever is applicable. A.nercra cess % / ate , ' Owner/Contractor Address 9S0 6le4A DAM 4;15.-4. lJygSb;o BY �� Estimated Starting Date aliCkjol Completion Date ItItt1t� 0 Permit Expiration Date._ 2.1 r Ito I (or We) hereby apply for an Encroachment Permit to carry out the following work: Qr`¢S�+rt 0•� -e*;4*.3 kr.roll Ly ul ) 011 xtm V-16 41.11 a aag& of 3 Cc .4 4kla.eI bl SJ{rr2. n bSG O -1 Atrc*be & `tom LwLr1 --SL CCksc"e Oriltln,dr 5nc. crm1� a c onr r tAe 'r Mycl raven ca e" a6ol e. Ass n r Vr 4A tva l and r=OW W _< rAte - ' ATTENTION:Applicant/Contractor—you are responsible to _ replace all broken,damaged,and/or raised sidewalk,curb and PERMIT FEE........................... $ S 4 00 gutter from score mark to score mark adjacent to the parcel; remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $ -tt*�- ' The above named lb ;mal.: Sewer Tap Deposit. $ ................. li 1TOTAL DEPOSIT ...... $ CBuilding Peimit No. ,> Improvement Plan No. )r Supplement Conditions ii4 t VP/er �cSta/a.tien Ska 1/ ��ci°mV&-C&,f i ' 4'r PERWROTYIWOWITHOUTAOA '61A Si4��•/`6ONTROLNUII OLIHS CALL (299) 937-&9% TO REQUEST A CONTROL NU)IBER NO LESS THAN 24 HOURS, BUT NOT ` 't '� EXCES�SpOF 72 HOURS PRIORTo START OF WORW Show sketchb 11ted' GON t r SOL —_— IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit,as well as all applicable city ordinances,resolutions, ' 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 not meet the above requirements.Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnity and hold the City harmless against any and all losses,costs,or damages resulting from injury toPersons, death of person or damage to property 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 Manager prior to issuance of this permit. ' IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937.8411 FOR SPECIFIC ' INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937.8381. READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. Signed; _ Phone: 4/6r 70)11 ' Ial-Permittee(while) 2"d-Inspection(pink) 3"t-File(yellow) 41b-Finance(white)