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CITY OF STOCKTON 1D 3 PUBLIC WORKS DEPARTMENT RECIEN07 5 M05APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY If AUG 3 nn Applicant's Name AJ d /3 APPROVED: BY THE PUBLIC JOW DIRECTOR (Owner/Contractor)• �-7 y,/ Address �3 7 S�4,A PO4� Phone) —I2)3y Subject to the Generallai"%nditions, and all work must conforVroved Storm City Q"bwAesrl State zip .1's2rs Water Pollution Prevention Plan or the most current version Location of Proposed Work, etc. ;'� of the City of Stockton Storm Water Pollution Prevention P Maintenance Staff Guide, whichever is applicable. Qeattxr, Owner/CantractorRddress Oil-t-4By Date Estimated Starting Date Q--tq—Q Completion Date 10— 1^ C22F Permit Expiration Date 1-19 I (or We) hereby apply for an Encroachment Permit to carry out the following work: -t t /� �7 G Cfi ATTENTION:Applicant/Contractor--you are responsible to C7 replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FE ........................... $ ,J 2, gutter from score mark to score mark adjacent to the parcel; Tee 7- remove USA markings upon completion of the permitted work. A a oo ag $ �} II The above named applicant hereby requests permission to ................. f_ TOTAL DEPOSIT ...... $ < /� Building Permit No. Improvement Plan No. Supplemental Conditions: �xglG LOItf/v ply "Crak.,\_ 470t 3�PERMIT V40T VALID MTHOUT A CONTROL NUMBER. CALL. (209) 9374M TO REQUEST A CONTROL NUh�:IIBER NO LESS THAN 24 HOURS, BUT NOT IN EXCESS OF 72 HOURS PRIOR TO START OF WORK. CONTROL# Shaw sketch above or reser to drawing submitted IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit, as well as all applicable city ordinances, resolutions, 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 not meet the above requirements. Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnify and hold the City 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 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 of this permit. IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE-REVERSE SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937-8381. READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. Signed: W� Phone: 15'-Permittee (white) Zed-Inspection (pink) 31d-File (yellow) 4=h -Finance (white)