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CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT 70150 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY AP_Od 543/3 <br /> Applicant's Name Date �`� APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) e O Subject to the General Provisions and Special Conditions, <br /> Address -- Seo �w7 Qr Phone A3? $ ` and all work must conform to the project's approved Storm <br /> City State Zip �.z Cs{ Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. �C,.dL� w 4aw ,,. ( of the Ci of Stockton Storm Water Pollution Prevention <br /> Mainten nce Staff Guide,whichever is applicable. <br /> Owner/Contractor Address G S By Date <br /> Estimated Starting Date '9Z 13C G Completion Date G t C C Permit Expiration Date 0 o1 O fo <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: f v.s lc u�`?•v c a 2 �cn. <br /> c /f <br /> Gu� �wo,,;�.3t�^>.L't we,�� GJv�S.�i�:t..t� C4 f�� f�. Fa �;� pyC e (ty a, 11, �-a F[ <br /> >✓r�.e...o,� ri t( �.;'E"�.�� C` �� 3�� � ��-:�i-+nst.`f�.;- � �.�(�. . �••Q.LI +�- t( <br /> ('�✓t l <br /> "A' Ut k 3`z� v .I l..'�A, N, k�!^v� n,�fi(da n c c`� V. ( � <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 ...... $ /04�+ <br /> Building Permit No. <br /> Improvement Plan No. <br /> -;- Supplemental Conditions: <br /> •¢ Lam, <br /> Q PERMIT NOT VAUD WITHOUT A <br /> CONTROL.NU R. <br /> C= n z CALL (209) 937-&3$6 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURSS IOR TO START OF MRK. <br /> CONTROL.,# s05 0 5 0 A <br /> Show sketch above or refer to drawing submitted <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 /> Signed:A;x Phone: 3 <br /> 1s'-Permittee (white) 2nd-Inspection (pink) 3rd-File (yellow) 4th -Finance (white) <br />