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CITY 0,F.STOCKTON... 71735 <br /> PUBLIC:WORKS DEPARTMENT <br /> APP,LICATIO.N.FOR ENCROACHMENT-ON PU-BLIC. RIGHT-OF-WAY _ <br /> Applicant's Name•rl �� I APPROVED: BY THE PUBLIC WORKS.DIRECTOR <br /> -- _ - <br /> (O n Txontcactor) }} -7 <br /> Address ��S S' a �Oa_4C Phone l _10( Subject to the General Provisions and.Special•Corditions, <br /> 1�_ �p�� and all work must conform totheproject's approved Storm <br /> City 717(Lmt /E State Zip 521 Water Pollution Prevention Plan or the most current version <br /> Location bf'P�oposed Work, etc. W�. of the City of Stockton Storm.WaterrPollution Prevention <br /> Maintenance Staff Guide,whichever is applicable. <br /> Gwner/Coritractar Ad` <br /> dress. C�' By Date <br /> Estimated Starting Date. Q Completion Date l0 P �� �{ Permit•Expiration Dale <br /> I (or We) hereby,apply.for,an Encroachment Permit to.,carry out the-following work:. <br /> - - - --- <br /> ATTENTION:.Applicant/Contractor-you are responsible to C <br /> replace ail broken,dam°aged,'and/or raisedsldewalk,:curb and PERMIT=FE $ ./ <br /> •.. . <br /> utter from score,mark to score mark adjacent to the parcel; �� � ' � L?i <br /> remoVe USA markings upon,completion of,the permitted.work. A a:' 00 age. . ::........ :$ . <br /> ' Tfie above named`applicant herehy requests permission io: � ! ® �•- <br /> .................. <br /> f <br /> 7&AL.DEPOSIT ...... $ -5 <br /> ' Buildirig'Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: r <br /> EER�IIT NOT VALID THOU 'A <br /> CONTROL NUK6tR. ' <br /> CALL (209) 937-8366 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT 140T IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> CONTROU <br /> ' <br /> Show sketch above or refer to drawing subm'dted <br /> IMPORTANT:'Applicant•herehy agrees.to comply with all provisions of•tfiiis perrnit,'as well all applicafile city ordinances,resolutions, <br /> Standards and.Specifications-currently in'effect;and to pay to the City its actual cost..foe.rernoval and proper replacement of any item which <br /> does.not'nieet•the`above requirements. Failure to comply will be cause for revocation of this permit:-Applicant agrees to indemnify 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 Cf1Y PROJECT ENGINEER AT(209)937-8411 FOR SPECIFIC <br /> INSTnucti]NS 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 /> �.. Signed: `' Phone: <br /> 11�-Permittee (white) 2nd-Inspection (pink) 31d-File (yellow) 41h-Finance(white) <br />