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aITY OF STOCKTON 75943 <br /> DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY�� <br /> Applicant's Name A Vcwt(e3 Get,&hyw\rr��Date�2- APPROVED: 13Y TH e�� RECTOR <br /> (Owner/Cg. tractorra )� n ��\ phone 7u�`W&7-/00L - Subject to the General Provisions and Special Conditions, <br /> Address-4-�TCCS4 It/C 1 - and all work must conform to the project's approved Storm <br /> City 5- �c` - State �> Zip q Water Pollution Prevention Plan or the most current version <br /> of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. G.�rio ' _ Mainten ce Staff Guide,whichever is applicable. <br /> Owner/Contractor Address S e0Do By Date <br /> Estimated Starting Date © Z Completion Date 1�7,k l ZCiZ Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: &,j •P <br />` r <br /> A4 VJATTENTION:ApplicanVContractor—you are responsible to 7 ? �- <br /> replace all broken,damaged, and/or raised sidewalk,curb and PERMIT FEE........................... <br /> gutter from score mark to score mark adjacent to the parcel; -rr,"fo !�r v r• <br /> remove USA markings upon completion of the permitted work. Additionalee#aga Fee .......... $ <br /> The above named applicant hereby requests permission to: 6 <br /> Sewer Tap Deposit.................. $ Z, 6 <br /> 77 1 <br /> TOTAL DEPOSIT ...... $06!r <br /> Building Permit No. <br /> Improvement Plan <br /> No. <br /> Supplemental Conditions: <br /> CONTROL NUMBER. <br /> CAU. (209) 937.8386 TO REQUEST A CONTROL <br /> f4UMBER NO LESS THM 24 HOURS, SUT NOT IN <br /> EXCESS 0F. 72 HOURS PRIOR TO START OF WORK. <br /> CONTIROL9 <br /> I <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 <br /> Ir does not meet the above requirements. Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnity and hold ; <br /> the City harmless against any and all losses, costs, or damages resulting from injury to persons, death of person or damage to property <br /> occurring at the site of, or as a result of, work to be performed under this permit.A certificate of insurance shall be submitted to the City Risk <br /> Manager prior to issuance of this permit. <br /> IF THE WORK DOES NOT COMMENCE 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 AT209 <br /> ( )937-8411 FOR SPECIFIC <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE <br /> SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937-8381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING, <br /> I <br /> Signed: j,�q `� Phone:- y&7'j�l'.J <br /> 15'-Permittee (white) 2nd-Inspection.(pink) 3rd-File (yellow} 41h-Finance (white) <br /> 1 <br />