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Permit Number <br /> C.TYOF ENCROACHMENT PERMIT Ep�g_Zp� <br /> LSTOCKTION <br /> ON PUBLIC RIGHT-OF-WAY <br /> Applicant: , v 1•- Date:,:1 NJII L J APPROVED:BY THE DEPARTMENT DIRECTOR <br /> Z Subject to the General Provisions and Special Conditions,and all work mus <br /> q W/� /J conform to the project's approved Storm Water Pollution Prevention Plan at <br /> Address: (3 �r _s in he most current yersices of the City of Stockton Storm Water <br /> Pollution Prevend Maintenan Staff Guide,whichever is applicable. <br /> City: State: ✓�' "P:I� Q Iz��^N <br /> Phone: 7.'-1-2 R-R, 3 E.maa: 1r44t-�d /�1r15 p <br /> ssWated Permits): existratlow. Jr 3. I <br /> WORK LOCATION:,, -'T f r,Jlli us •, :.;c:iltiL�U�A <br /> f •s <br /> Start Date: I'-i-(� Completion Date: �'/1:� <br /> (itiG=A COMOL <br /> UM602'�''�) I r r•11�aoYc1 Z�®t{OltRfl./!liT.e���T[wsa�aP <br /> ATTENTION:Applicant/Contractor-you are responsible to replace all broken,cl.—ged, � .� <br /> and/or raised sidewalk,curb and gutter from score mark to score mark adjacent to the Q�s af +� <br /> parcel;remove USA markings upon completion of the permittedwork. <br /> I(or we)hereby apply for an Encroachment Permit to carry out the following work: <br /> o 1,5'4TiI/ k y✓c- 41414 <br /> Show sketch or refer to attached Drawing <br /> Official Use Only <br /> Base Permit Fee $ Sz3'CD <br /> Additional Footage Fee $ <br /> Misc. Cpm $ 31. 3g <br /> _ Misc, T6A-I F-66: $ 3�.2.3 <br /> �L E Misc. $ <br /> Total <br /> Special Conditions: <br /> 3If f 2 <br /> IMPORTANT:Applicant hereby agrees to comply with all provisions of this permit,as well as all applicable city ordinances,resolutions,Standards and <br /> Specifications currently in effect,and to pay to the City Its actual cost for removal and proper replacement of any Item which does not meet the above <br /> requirements.Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnify and hold the City harmless against any and <br /> all losses,costs,or damages resulting from Injury to persons,death of person or damage to property occurring at the site of,or as a result of,work to be <br /> performed under this permit.A certificate of Insurance shall be on file with the City Risk Manager prior to Issuance of this permit. <br /> IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE �! <br /> OF A CONTROL NUMBER,THE CONTROL NUMBER WILL BECOME INVALID <br /> AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER. PRIOR TO rte' <br /> ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS Sign <br /> PERMIT,PERMITTEE SHALL CALL INSPECTIONS AT(209)937.8381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE - --5" <br /> SIGNING. Print <br />