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05/15/2006 12: 23 916278317i` `� USGS PAGE 02 <br /> ow CITY OF STOCKTON <br /> 70151 <br /> PUBLIC WORKS DEPARTMENT <br /> 15 APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> '•SR�� <br /> Applicant's Name C-05— Ku b —Date "I V o C APPROVED. BY THE PUBLIC WORKS DIRECTOF <br /> (Owner/Contractor) Subject to the General Provisions and Special Conditlons <br /> Address 15GO �ay-f Qr;.iQ Phone `��7 g��O j <br /> - and all work must conform to the project's approved 8torn <br /> City State CZip WaterPol Ion Prevention Plan or the most current versioi <br /> of the Ci of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. ATke¢ T*— Mainte ce Staff Guide, whichever is applicable. <br /> C ._o•i k L e V--c 6 <br /> Owner/Contractor Address L" 6 U $ By Date <br /> Estimated Starting Date- S� I J51 D Ga Completion Date l S 0IS Permit Expiration Date d <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: �O 16rt��c�.yh J� "'� � "^" (7 <br /> Tt+ <br /> L..-t A I <br /> f <br /> 6�C'�-�f a(( w��1..�v\ � t� �`'t �i l-••...e�T'e� fp>(t-�t��7. �Q, •ZT h/� <br /> ATTENTION:Applicant/Contractor-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. Additional Footage Fee .......... $ <br /> The Above named Applicant hereby requests permission to: <br /> Sewer Tap Deposit.................. $ <br /> TOTAL DEPOSIT ...... $ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions; <br /> PERMIT NOT'Ill WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 937-$386 TO REQUEST A CONTROL <br /> NUMBER NO LESS Tl M 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> CONTROL$__ <br /> .Show sketch above or refer to drawing submitted fl 10 A n rto.� 7 <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)637-8411 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)937-6381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Signed: Phone: ��7- L9 f0 <br /> 151-Permittee (white) 210-Inspection (pink) 3"-File (yellow) 41h-Finance(white) <br />