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CITY OF STOCKTON 6 6 6 6 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> pplicanCs Name C2ML I R-VAN I IVC_Date I k 0 APPROVED BY THE PUBLIC WORKS DIRECTOR <br /> {O wnerlcontractor) Subject to the General Provisions and Special Conditions,and all <br /> Address 31,10 Got0 C AM 2 Dt .� Phone l -631- 13oo work must conform to the project's approved Storm Water Pollution <br /> City$�+f�1f' ftQ0.�y 4 State�— Zip 'i-a-4 7c7 Prevention Pian or the City f Stockton Storm Water Pollution <br /> _ Prevention Maintenance S ff Guide whichever is applicable <br /> Location of Proposed Work,etc r 0� :' 1661 tRX(JEIL A Vim.Nlltr 7 <br /> Qwnerl Contractor Address By Date l_� <br /> Estimating Starting Date 3 -14-o ,2- Completion Date - a' a it Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work I sl'-11 <br /> Coni-rel # D228oA <br /> The above named appbcant hereby requests permission to <br /> PERMIT FEE $ V <br /> I <br /> Additional Footage Fee $ <br /> Trench Fee $ <br /> Sewer Tap Deposit $ <br /> �gttJ� TOTAL DEPOSIT $ C <br /> a <br /> AN <br /> Building Permit No <br /> r <br /> pj�►3 T` Improvement Pian No <br /> Vi <br /> Supplemental Conditions <br /> Vol VitAt <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 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 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 /> ERMIT IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> COME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER (FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> UBDIVISION 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 RE SIGNING PhoneG6 ` <br /> Signed 4) <br /> tst-Permittee(white) 2nd-Inspection(pink) 3rd File(yellow) 4th-Finance(white) <br />