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CITY OF STOCKTON <br /> PUB le-WOrMM DEPARTMENT 77138 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> 7-Etenn.th&Wo <br /> Applicant's Name _S#arlkC Cog5&tl41IArfcS Lt. Date 03 .14 <br /> WIV APPROVED: BY THE PUB teTfOM DIRECTOR <br /> (Owner/Contractor) Dabit tA�Gnb� t^ <br /> Address $017 Kt Igofzthad.Su.►�c lob Phone�'6-3Py-o6.it/ Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City )44tho &1e11d& State M Zip 1 (5= Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. 40066 N.P4,9664 4 Ge -O&A of the City of Stockton Storm Water Pollution Prevention <br /> Maintenance Staff Guide,whichever is applicable. <br /> Eloft#17a3q-Y561 Al 8� bb Are <br /> Owner/Contractor Address (. By I LQJ tAb Date U" 1 <br /> Estimatd_Starting.l a Completion Date�/ Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> Lana Clobwu at KW-y /0c4,f1irl 44 3 4M!yk d3 {n i� G�_ /4 ?) 114(//llcsf�uci . <br /> 3) #Wh.4# AA,&u 44 um Ly� Amex <br /> (to I1 AS 11 d told-eA 4000kblt p,.L&Yld 'g9716) - <br /> ATTENTION:ApplicanVContractor—you are responsible to <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; <br /> remove USA markings upon completion of the permitted work. f"t$ 23 <br /> The above named applicant hereby requests permission to <br /> TOTAL DEPOSIT .....: $ Z <br /> Building Permit No. <br /> Improvement Plan No. <br /> ll t, ,�,,� Supplemental Conditions: - <br /> CORTROL Vt��r ��. <br /> CALL (209) 937-K55 TO REQUEST A CaNTTROL <br /> NUNIMER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORY. <br /> =rv = <br /> tt�j)z\. P�-r < <br /> Show sketch above o refer to drawing submitte C �� ��� --CL f NS���Y <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 /> does not meet 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 CITY PROJECT ENGINEER AT(209)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 /> Signe4XV <br /> v/�''Y7K/Phone: 916-3P1-�?a� <br /> $5,d C U t <br /> ts! D-ittnn/...hits\ Ind_Incnentinn /nin41 qrd_File /vellnvu.l Alh_Finnnrc/%erhitel <br />