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CITY OF S N <br /> zff C�DttCiNORKS DEPARTMENT 76005 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name _/1RGAaLS—US T�fc Date <br /> (owner/Contractor) Ivita-hZ APPROVED: BY THEZ&RKS DIRECTOR <br /> Address 2000 07Wea f 5* 900 Phone 510.6SZ.—yS00 Subject to the General Provisions and Special Conditions, <br /> City_ �MerV✓iIIG State and all work must conform to the project's approved Storm <br /> Zip_.9 608 Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. of the City of Stockton Storm Water Pollution Prevention <br /> �J Maine nce Staff Guide,whichever is applicable. <br /> M Sen llo tri✓ • ' iro�en Pd1-& �. <br /> Owner/Contractor Address By e/ � Date 7 <br /> Estimated Starting Date 1Q— Zz_// Completion Date_l� /—/Z Permit Expiration Date 17—If—/Z <br /> I (or We)hereby apply for an Encroachment Permit to carry out the following work: <br /> Vrill and =n / -{r?�nj s¢' U arrxtndwcrier Monikrtnq we//s tiSo A <br /> YylaktlMunyt n"A e-F — lye, -Mr-� .-E- of rrrrMeala�ian ac/ivl-�tec fi r <br /> tB Lin / Cen Sr .s tier Ipr {,-( <br /> ATTENTION:Applicant/Contractor—you are responsible to <br /> replace all broken,damaged, and/or raised sidewalk,curb and / <br /> gutter from score mark to score mark adjacent to the parcel; PERMIT FEE........................... $ 7 <br /> remove USA markings upon completion of the permitted work. ci Z 3 <br /> Additional Footage Fee.......... $ 37 — <br /> The above named applicant hereby7pamissionto /� y� <br /> Sewer Tap Deposit.................. $ 7 -- <br /> TOTAL DEPOSIT ...... $ Z 6 9 <br /> Building Permit No. LP <br /> Improvement Plan No. <br /> P �),$ppple e t <br /> 'CONTROL NUMBER, <br /> CALL (209) 937.8388 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 2� HOURS, BUT Dpi M <br /> EXCESS OF 72 HOURS PRIOR TO START OF WQX <br /> CONTROIat <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,res'AAlons, <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 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 OJECTS OR <br /> SUBDIVISION IMPROVEMENTS, E MITTEE SHALL CONTACT THEASSIGNED CTY PROJECT ENGINEER AT(209)93OL NUMBER.(FOR CAPITAL 7.8418 OR 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)9374361. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Signed: A�E= Phone: �)�•��USOb <br /> 1-'-Permittee(white) 2nd-inspection p (pink) 3r°-File(yellow) 4'^-Finance(white) <br />