Laserfiche WebLink
�CITY OF STOCKTON <br /> 6 WAFtKS DEPARTMENT 75207 <br /> ' APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name Gf4K(,J C605V>VANcS c%J�;r•E Date n 1 •• APPROVED: BY THE B17C�VOftl <br /> ES DIRECTOR <br /> (Owner/Contractor) <br /> ' Address Lk, >r$00 Phone_(91G)I;SZ-`118 Subject to the General Provisions and Special Conditions, <br /> Cit ILcwc.No r and all work must conform to the project's approved Storm <br /> Y CaR�JA State CIa Zip H��4Z Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. i� a K NE/*e y ,mss_� of the City of Stockton Storm Water Pollution Prevention <br /> ' Maintenance Staff Guide, whichever is applicable. <br /> or PAGS�i�AJ£. ANr) 'y./, fly- �z / <br /> Owner/Contractor Address 3iCoC,000Vryq I p2 tf g By /� <br /> ' Estimated Starting Date Completion Date o; k ZoOL fff Permit Expiration Date Z <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: 17 E Snt<, Fi�aTt M �pra zsw <br /> t -rte a?I F'baro�i+— Cc ..�E4.y U TAGS fZG <br /> NEN vG AwD W IZ�°� Nc�D <br /> ATTENTION:ApplicanVContractor-you are responsible to -7 a <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; <br /> e - <br /> remove USA markings upon completion of the permitted work. Addl� <br /> tional Footage Fee .......... $ 3 <br /> The above named applicant hereby requests permission to: of <br /> LSE 7Gt S <br /> AT%*Lt�Cj GSh�' 1A _ %C ewer Tap Deposit.................. $ ) I L <br /> ' sy <br /> TOTAL DEPOSIT ...... $ O <br /> Building Permit No. <br /> ' Improvement Plan No. <br /> Supplemental Conditions: <br /> ' Pki4ii-NOT VALID WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 937-&W TO RE(UST A C(3N'M% <br /> ' NUMBER NO LESS THIMI24 HOUK 8U1 WT IN <br /> EXCESS OF 72 HOURS PRfDR TO STM CF IIQM <br /> CONTRW <br /> 1 <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 /> T SUBDIVISION ) <br /> UCTIONS PRIOR TO THE BEGINNING NG OF ANY WORK)PRIOR 0 OR ANY REQUIRED INSPECTIONS, IDENTIFIEDCTIIONS,AS (ENT <br /> 937-8411 FOR SPECIFIC <br /> NSRIDENTIFIED 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: �C� Phone:6IC) <br /> 1 st-Permittee (white) 2nd-Inspection (pink) 311-File (yellow) 41h-Finance(white) <br />