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CITY OF STOCKTON PUBLIC WORKS DEPARTMENT `�L) L) " APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY plicas Nam T AQjr' "'pate ca APPROVED BY THE PUBLIC WORKS DIRECTOR caner/contractor) !} Address �� f�L`r ,jy��- Subject to the General Provisions and Special Conditions,and all Phone work must conform to the project's approved Storm Water Pollution City >�7' _i StateCPA' Zip Prevention Plan or the City of Stockton Storm Water Pollution Prevention Maintenanc Staff Guide,whichever is applicable Location of Proposed Work,etc _ 2�l�2"��er�f�l� ,�j'L f/ ' Owner/Contractor Address_, .� 7 .- _ Bye Date f�' •C� ._._ Estimating Starting Date 4. — lJ Completion Date / -AL3 )�p ermit Expiration Date oZI 15L,0 Z I (or We) hereby apply for an Encroachment Permit to carry out the following work The above named appkcant hereby requests permission to PERMIT FEE $ `C' Additional Footage Fee $ Trench Fee $ L{ Sewer Tap Deposit $ Q TOTAL DEPOSIT $ Building Permit No Improvement Plan No Supplemental Conditions Show sketch above or refer to drawing submitted IMPORTANT. Applicant hereby agrees to comply with all provisions of this permit,as wolf as all applicable City ordinances resolutions Standards and 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 requirements Failure to comply will be cause for revocation of permit Applicant agrees to indemnify and hold the City harmless against any and 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 performed under this permit A certificate of,nsurance shall be submitted to the City Risk Manager prior to issuance of this permit PERMITTEE SHALL CALL(209)937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER (FOR CAPITAL IMPROVEMENT PROJECTS OR APIVISION IMPROVEMENTS PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR CIRC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK) READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERMIT B E SIGNING / / p Signed 4 Phone 1st-Permittee(white) 2nd Inspection(pink) 3rd File(yellow) 4th Finance(white)