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Sep 08 05 11 : 10a C= ' y of Stockton (2F '1937-8901 p. 2 ._ . x..,.. CITY IOF STOCKTON PUBLIC WORKS DEPARTMENT 6 9 APPLICATI/OWFOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY Applicant's Name C j L- %��U/J Date `� i J.� APPROVED: BY THE PUBLIC WORKS DIRECTOR (Owner/Contractor) r Subject to the General Provisions and Special Conditions, Address ✓ �dK�// Phone / �� )ly and all work must conform to the project's approved Storm City� ��ric- ',�pL_State t _Zip rS2.,)6 Water Pollution Prevention Pian or the most current version Location of ProposeclAork, etc. of the City of Stockton Storm Water Pollution Prevention I G Maintenance Staff Guide,whic ever is applicable. Owner/Contractor Address . 5., B Date y ,,�r ` Estimated Starting Date q J Completion Date Permit Expiration Date I (or We) hereby apply for an Encroachment Permit to carry out the following work: t (r J. 0 - ' r I - Imacvcft I ATTENTION:ApplicanVContractor-you are responsible to / � ............ v �5 replace all broken, damaged, and/or raised sidewalk,curb and PERMIT FEE............... $ Z 6 gutter from score mark to score mark adjacent to the parcel; j remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $ I The above named applicant hereby requests permission to Sewer Tap Deposit..............:... $ � � r� 11 ,. r1 . A TOTAL DEPOSIT ...... $ Building Permit No. Improvement Plan No. Supplemental Conditions: 06 Show Show sketch above or refer to drawing submitted IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit, as well as all applicable city ordinances, resolutions, Standards and Specifications currently in effect,and to pay to the City its actual cost for removal and proper replacement of any item which does not meet the above requirements. Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnify and hold the Citv harmless against any and all losses.costs. or d;4manac resulting from injtiry tr,nmr--, death of person or damage to prcperty occurring at the site of,or as a result of,work to oe performed under this permit.A certificate of insurance shall be submitted to the City Risk Manager prior to issuance of this permit. IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937-8381. READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. . Slgnedy f.L ) 'fl Phone:_ `1 j r7 J