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11/17/2093 10 51 9166610436 SECOR PAGE 02/13 <br /> ri CITY OF STOCKTON (r"7 0 IPV <br /> 6 7 9 ' 2 <br /> . PUBLIC WORKS DEPARTMENT <br /> OM95 APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> cpplleBnt's Name Date 10APPROVED, BY THE PUBLIC WORKS DIRECTOR <br /> Cress'll, <br /> Phpne�ii/•5 �'/�� Subject to the General Proytsions and Special Conditions, Joll <br /> work must conform to the project's approvo4 Sinrm water <br /> �Y.Li r S to ! rL Zip GI y �(� Prevention Plan or the City of Stockton Storm water Poll~ <br /> _L��L_ -1 Prevention Mantenance Staff dards,wMchever Is applicable <br /> Locadon of Proposed Work,aro <br /> �` r 107 0Adds By DataEabmabng Starting Date go3complet'on Date Permit Expiration D&18 -r�0 <br /> I (or We) hereby apply for an Encroachment Pemit to carry out the following work <br /> .a I M r'!Ifon w is -9 G nDt. <br /> 1 1�101t[n 9d <br /> I In <br /> vourdvl' x t t g 1 fIftA dId• <br /> 40 G X24 51�TIr rnmru 1P as IYIC�hldr fmh- 0 r I�l I esu er'� <br /> The 06"namad omkxnl hgraby Fewasis patmkilon to <br /> 2 PERMIT FEE S <br /> vv ` Additional Footage Foe s <br /> Trench Fee S <br /> Sewer Tap Deposit $ �— <br /> . q TOTAL DEPOSIT $ a <br /> Lire/ IVI <br /> Building permit No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> se. RP 03-z1L-%J <br /> Www sko"Abwa or rotor to dr%wft samiltr4 <br /> IMPORTANT. Applicant hereby agrees to earttply with all provisions of trus permit,as Well as all applicable City crdlnancas,resolutions, <br /> Sumutards and Specifications currently to effect,and to pay to the Gty Its actual Bost for removal and proper replacement of any item which does <br /> not rnsof the above raquiremiora Failure to comply will be cause for revocation of parrnit-Applicant agrees to Indemnify and hold the City <br /> harmless against any end all losses,cost$,or damages resul1ing front Injury to persons,death of person or damage to property occurring at the site <br /> of,or as a result of,work to be perlormed under thls permit A certificate of insurance shall be subrn tted to the City Rlsk Manager prior to issuance <br /> of this pertNt. <br /> PERMr TEE SHALL M21 1j37-143�FOR A ONTAOL NUMBER NO LESS THAN 24 HOURS,BUT NOT 10 EXCESS OF 72 HOURS, <br /> PRIOR TO THE START RK AND P ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT' IF WORK 00 ES N MTHIN 72 HOURS OF THE ISSUANCE OFA CONTROL,NUMBER,THE CONTROL NUMBED WILL <br /> ECIFIC <br /> ME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER (FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> IVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)8978411 FOR <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK) <br /> READ GENERAL PROVIrAONS ON REVEFISE BIDE OF THIS P MIT BEFORE SIGNIN0 /fes <br /> s%M d*0 k S/1'. <br /> PhoneIf <br /> 151-porntlitse(Wwa) 2nd-Inspection(pink) 3rd Rio(yellow) 4th Flnanoe(%*It@) <br />