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N../ CITY OF STOCKTON 6 � C <br /> PUBLIC WORKS DEPARTMENT <br /> M& APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> M57W <br /> Applicant's Name Mi-!EV,•I'RYL Date - '11-02- APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) Subject to the General Provisions and Special Conditions,and all <br /> Address 3NO MP 5yrtr 176 Phone qtl y 63t- 1300 work must conform to the projects approved Storm Water Pollution <br /> Zip W6 70 Prevention Plan or the City f Stockton Storm Water Pollution <br /> City �?At�tGFra Cc�!RDo�+A State C <br /> l - Prevention Maintenance S E.Guide whichever is applicable. <br /> Location of Proposed Work,etc. m304' <br /> Owner/Contractor Address By Date - -Q <br /> Estimating Starting Date 3 ~y—o '2- Completion Date ivrit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: InIT-11Z <br /> Mom�0t'% l�S <br /> The above named applicant hereby requests permission to- O0 <br /> PERMIT FEE....................... $ (.✓� <br /> Additional Footage Fee............ $ <br /> Trench Fee............................... $ <br /> TaE�� 0 Sewer Tap Deposit.................... $ <br /> TOTAL DEPOSIT.........$ '. <br /> t' <br /> Building Permit No. <br /> c p,UN 01 Improvement Plan No. <br /> Supplemental Conditions: <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 does <br /> not meet the above requirements.Failure to comply will be cause for revocation of permit.Applicant agrees to indemnity 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 prior to 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 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 <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL.PROVISIONS ON REVERSE SIDE OFT S ER B RESIGNING. J 1, <br /> Signed: Phone: 9Ia 6 S f 36 1) <br /> 1st-Permittee(white) 2nd-Inspection(pink) 3rd-File(yellow) 4th-Finance(white) <br />