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• CITY OF STOCKT <br /> CBI=F6�AtARKS DEPARTMENT <br /> 75207 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> C uJf,r Fwgd_ - <br /> Applicant's Name Gg ✓ � C"J -TAN" Date r. >,8 ,. APPROVED: BY THE IRECTOR <br /> (Owner/Contractor) Subject to the General Provisions and Special Conditions, <br /> Address 3t L' C�c"°i%Aue1 �. ��� Phone ( 16 W Z"Illi and all work must conform to the project's approved Storm <br /> City IZA,•+cishe t-.G20pJA State CPQ Zip '115142 Water Pollution Prevention Plan or the most current version <br /> of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. S Win=WALk Pi,,Are 7+"*E,2�r�'ns^� Maintenance Staff Guide, <br /> whichever is applicable. <br /> p' ?AGSGZL AJ'.. prJ7 � ,..r 12- <br /> Owner/Contractor Address.3'LO C Vn E �Dz s" By /e <br /> Estimated Starting Date oJc i/lo,L Completion Date o. 13t J 2oiz Permit Expiration Date "-�— <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: 17 E y f2v t M ra 2y,,,' <br /> LJEt.tri pLf...a l-1 ttM <br /> ALL- — — ec EeS �Acyasc <br /> AvEN C AND W 12"c5S,, &" <br /> ATTENTION:Applicant/Contractor–you are responsible to 6w <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; O <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $ <br /> The above named applicant hereby requests permission to: t �L <br /> Sewer Tap Deposit.................. $ 1 <br /> TOTAL DEPOSIT ...... $ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PLr4 i' NOT VALID WITHOUT A <br /> CONTROL NUMUK <br /> CALL (209) 937-M TOREQMT A MMIROL <br /> NUMBER NO LESS T"24 HOU& Nn WT IN <br /> EXCESS 0F72HIX0F DRTO9111 QF=K <br /> CONTAW <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: Phone: <br /> 15' -Permittee (white) 2"d -Inspection (pink) 3rd -File (yellow) 411-Finance (white) <br />