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0 �°0)5w <br /> 4 <br /> CITY OF STO <br /> PUBLIC WORKS DEPARTMENT <br /> RT MENT lV <br /> .APPLICATION FOR ENCROACHMENT ON PUBLIC:FIGHT-OF-WAY LP.���+ 19 <br /> GY4CCrQ o{" nu.t kl OE en' �y APPROVED- BYTHEPUBLIC WOR DIRECTOR <br /> ApppNcan Name_ 1! g`"—"— <br /> (Owne ontracto )� Subject to the General Provisions and Special Conditmns,and all <br /> w Phone <br /> -P& `, ' work must conform to the projects approved Storm Water.Pollution <br /> Addres�s. � 0-•+lx Q'`�" - Prevention Plan or the City of Stockton Storm Water Pollution <br /> City "�•�T��._�"'"R _—State _ P—. '— Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location ofProposed Work,etc. +Lille <br /> G I� <br /> 24— <br /> $,) 1 1G 4.Y hLl --''L•C.�.1'4 A __ BY Date - <br /> bmaee,Contractor Address <br /> .�1 .. Date�_1-"j ry Permit Etirafio� �_�'= <br /> Estlmating.Starting Date.T" _—Completion_ <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: ti �r .i <br /> Mtv1ti i�vz� tna�r. T; Ay iije- kj �n.c al� lf� <br /> 3'Q=0 <br /> 1� 6'T 1�Cf <br /> r TheoboVemmadapplr thBmbYre t$PArmmsbnm- PERMIT FEE................... .....$ <br /> R Z f—Vei <br /> Lt A 4JJ Additional Footage Fee,,........,.$ , <br /> 'meq Trench FSe........ ....$ <br /> p S t•)nrcc-Nk•y t'M%j-I(I Sewer Tap Deposit ... S. <br /> O <br /> j�V—tnY l.�J k< .5 , TOTAL DEPOSIT........$ <br /> Building Permit No. _ <br /> improvement Plan N4. O D ^ ,.r, <br /> Supplemental.Conditions: (COPY <br /> -eMw skeiih elw.re or reler m drawfng suemined <br /> IMPORTANT: Applicant hereby agrees to comply with all previsions of this permit,as well as all applicable City ordinances,resolutions. <br /> Standards and Specifications currently in effect,and to pay to file City its actual cost for removal and proper replacement of any item which does <br /> not meet the above requirements.Failure to comply will be Cause for revocation of permit:Applicant agrees to indemnify and hold the City <br /> 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 <br /> of,or as a result of,work to be performed under this permit.A certificate of insurance shall be submitted to the.City Risk Manager priorte issuance <br /> of this permit. <br /> PERMITTEE SHALL CALL(209)937-8366 FOR A CONTROL_NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE START OF WORK,AND PRIOR TO.ANY:REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT,IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF ACONTROL NUMBER,THE CONTROL NUMBER WILL <br /> BECOME INVALID AND THE PERMITTEE SHALL CALL FOR ANEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR. <br /> SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT.ENGINEER AT(209)937-8411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS,ON REVERSE SIDE OF TMY <br /> ed . .MR BE�F�ORE SIGNING. PM1ona <br /> spcSign21sl-Pemh (white} <br /> 3rd-Rle(yellow) 4th-Finance-(white) <br />