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M ��CITY OF STOCKTON • <br /> �tlRl rr S.�noStS A <br /> APPLICATION FO965 <br /> R ENCROACHMENT ON PARTMENT 7 5 <br /> PUBLIC RIGHT-OF-WAY <br /> Applicant's Name �R cA p15-U �h ate D3 Va <br /> (Owner/Contractor) + APPROVED: BY THE DIRECTOR <br /> Address 01000 abl, 00 03t it �Floor• Phone 510_ (p!_6p Subject to the General Provisions and Special Conditions, <br /> City \\ State _ and all work must conform to the project's a <br /> —�Y i—e— zip r 1 pprrent Storm <br /> Location of Proposed Work, etc. (� Water Pollution Prevention Plan or the most current version <br /> nr�\h[i�an � h �pG�i�IC of the City of Stockton Storm Water Pollution Prevention <br /> �rAce QJ r Ar 4l Mainten Staff Guide, whichev is applicable. <br /> FiemCtmtt� I�o�t Ar <br /> Owner/Contractor Address �j <br /> Estimated Starting Date /p t a By Date�7/ <br /> 1 Completion Date 1 C) I S V Z <br /> Permit Expiration Date /1 —/f/Z <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> Dr•t\\ n on h 5 t b©1 in + i 140 CE e?+ b <br /> cctvll s �//�� <br /> Al .�/nedn1 Ce.n�-e II 11 Ce `` o r meAl <br /> 1Mon <br /> Q�Ivr1 a\wK[Q` lX t{alti lDn�re, 130rA, S CD dl1C 2Q V\r�cLQ(` O 2.TS h'Y d <br /> ATTENTION:Appllcant/Contractor—you are responsible to o v <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........................... $ <br /> remove USA markings upon completion of the permitted work. <br /> The above named applicant hereby requests permission to: Additional Footage Fee.......... $ <br /> Sewer Tap Deposit.................. $ �� N6 <br /> `&r <br /> NSG\ TOTAL DEPOSIT ...... $ <br /> FrI <br /> a <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PER T NOT VAUD WiTWILIT A <br /> CONTROL NU R. <br /> CALL (209) 937-&38,6 TO REQUEST A CON'iR% <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORCK. <br /> CONTRO <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 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 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: DI 1 Phone: 51 t� 591X�9(p3 J <br /> 1" -Permittee(white) 2nd-Insnection(oink) mFil <br /> _ (�J`-- <br /> e fvellnw) 41h-Finance lwhita) <br />