Laserfiche WebLink
CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT 7 19 13 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> M05 <br /> Applicant's Name /21dAnLzd 6eu Enuirana 1,111 Date 9 <br /> 6/9 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor yr �/ <br /> Address &,) F-.t Phone 1�:?IV06 Subject to the General Provisions and Special Conditions, <br /> J n� and all work must conform to the project's approved Storm <br /> City _-- z Livyk. State 6 Zip 952,1.i Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. �f�f�1151C(2_ CC Cr}+r 04%] onof the City of Stockton Storm Water Pollution Prevention <br /> p Maintena a Staff Guide, whichever is applicable. el," <br /> S1�tJn + �,t ha/ r Pat�Sir�e cf _S(Ztni:sltt9u� t) . YIPUv:.I _ / I <br /> d <br /> Owner/Contractor Address 4V I �. C IAQ'r ie,- lit CW By Date` �3 �0 <br /> Estimated Starting Date 1 V Completion Date /�-/Ol6 ermit Expiration Date <br /> 1 (or We) hereby apply for an Encroachment Permit to carry out the following work: 1 AAAA I Onr< l M oh t �rJ/v rlcl ell <br /> On Akdhs & S7ete c.LL94 E CLLd -( P-4" aKid Wo q'lLurcrL�a'kv mnnl 1Vf1146 twvy///S <br /> nn 'hu- Puc{ .sill isle+,i SJ-. imw 7t;jw., adpuz.f - A lc/ f=. ChakLy_ <br /> /j <br /> I/M L7 LGPS_S I II ea' L911 L + irZ. -Sl��t'biJei-1[,I�9n . <br /> ATTENTION:Applicant/Contractor-you are responsible to t' <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ SO d U <br /> gutter from score mark to score mark adjacent to the parcel; <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee .......... $ <br /> The above named applicant hereby requests permission to <br /> Sewer Tap Deposit. $ <br /> dr,4y"'h TOTAL DEPOSIT ...... $ S"b i't U <br /> `BaifQlhg Permit No. 13 tAL) <br /> L �f Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT NOT VALID WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 937.83813 TO REQUEST A CONTROL <br /> !DUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> Shaw sketch above or refer to drawing submitted FXCCESS�OFF�71.HOURS PRIOR TO START OF WORK. <br /> sl?NTanl � <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: �V"'l,'l,(, Phone: V�t � <br /> 1 s' -Permittee (white) 2nd-Inspection (pink) 31d -File (yellow) 41h-Finance (white) <br />