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S QCITY OF STOCKTON • <br /> SKS DEPARTMENT <br /> M APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name A PCADIS- US , ) " c Date n 1 t -2 APPROVED: BY THE P�RKS DIRECTOR <br /> (Owner/Contractor <br /> Address,ZOBo ��u7fl1� S� 7FIaxPhoneS)O -�oSl- �/S Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City E i uy4- u State C1 _Zip Jq(--� Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work,etc. 5i U2wu'k els lcm¢v,+ trnctE of the City of Stockton Storm Water Pollution Prevention <br /> Mainte ce Staff Guide, whichever is applicable. <br /> 351 L4uinc� anA '210(o LaS <br /> Owner/Contractor Address By ate <br /> Estimated Starting Date NCS I a1 La Completion Date Nov /S Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> Dr,(L CLAA \rV�Vct � Iw0 i2 a, 7110Co Sh (w ooc� on LJI%A mtc� © WP <br /> t Z51 'k►c 11 an �� UoocL a�o e�lci}ia vt�iu II r I- ul c�h ce Ec . zi <br /> IIlgvwk it COhd Lc�Il` I ®u(z")5 a gra tOA4 tua�r1ataII11tTh �bWW 'R 4 <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; 3 7 7- 1'remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $ / "— <br /> The above named applicant hereby requests permission to: <br /> 1 I � � Sewer Tap Deposit.................. $ �i� <br /> A(,° �9 <br /> S� TOTAL DEPOSIT ...... $ ��2 <br /> rMkQs . �2Vocu��+• <br /> Building Permit No. )I ,07V <br /> Improvement Plan No. <br /> Supplemental Conditions: �t <br /> N:FWASTI NOT VALID WI . i A <br /> CONTROL NUMER. <br /> CALL (209) 937-&W TO REOL,'EST A CM7ROL <br /> NUMBER ISMO LESS(�THM/2q4�HO(.1RS,, �/J'�T `WTT K. <br /> {PEEX�qC{{���E��Jyy''.�.7}}$$��O//F���{�{72I OURS PRIOR TO START OF V}VK1 <br /> CONTRIM <br /> J1,Y <br /> Show sketch above or 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 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 /> Signed /rl Phone: <br /> 1r!-Permittee(white) 2nd-Insoection(oink) 3rd_File fvpnnwl Aih hif.t <br />