Laserfiche WebLink
• CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicants Name nc. Date APPROVED BY THE PUBLIC WORKS DIRECTOR <br /> (OwneriContractor) Subject to the General Provoons and Special Conditions and all <br /> E <br /> Address d r k 170 Phonef%I��631— f work must conform to the project's approved Storm Water Pollution <br /> City g0LV%C—" fA143ovd� state cA zip_!35 6 to Prevention Plan or the city of Stockton Storm Water Pollution <br /> rr Prevention Maintenance Staff Guide whichever is applicable <br /> Location of Proposed Work etc as� S i 4.0 dic- C.A' M✓} <br /> U P <br /> Owned Contractor Address 31,44 Gold Can o 0,-y 174 14an[n, C�u,�rta�Q S�? BA Date U <br /> Estimating Starting Date l'ti1 2I O6 Completion Date 2irt Expiration Date-- <br /> I <br /> ate �[- - <br /> I (or We) hereby apply foran Encroachment <br /> {{Permit to carry out the following work To - <br /> c 1 fiG 1 2 l r A e-1 04 <br /> 1-7 20 I <br /> S18DA <br /> L ' tr <br /> The above named applicant hereby requests perm�Esion to <br /> PERMIT FEE $ <br /> $ Additional Footage Fee $ <br /> Trench Fee $ <br /> t ap j Sewer Tap Deposit $ <br /> ( TOTAL DEPOSIT $ <br /> 1 <br /> m Building Permit No <br /> C <br /> �m3i t Improvement Plan No <br /> `T Su plemental Conditions <br /> IX- <br /> e Jam' <br /> 4� �aC� .]vc Cic� 2L�`1111 <br /> Show sketch above W refer Iq drawng submi tedCL <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- 38 66 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 1F 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 SIDEOF IS ER RE SIGNING / �7` <br /> signed Phone 0 06 C 9 e — t 3o <br />