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Cl'I`Y OF ENCROACHMENT PERMIT Permit number <br /> � � _ $ <br /> STOCKTON ON PUBLIC RIGHT-OF-WAY <br /> Applicant: yC l��C�LI� ��� ��q y SSS Date: `— C ` y APPROVED: BY THE DEPARTMENT DIRECTOR <br /> J <br /> Z Subject to the General Provisions and Special Conditions,and all work mus <br /> a,hS �� O conform to the project's approved Storm Water Pollution Prevention Plan o <br /> LU <br /> Address: cn the most current version of the City of Stockton Storm Water <br /> JPollution Preventio aintena Staff Guide,whichever' pplicable. <br /> City: �� State: C ZIP: �s S Q <br /> LbC� SZ-2 �� 1b <br /> lig <br /> 1\�!` LL By: Date: <br /> Phone: E-mail: 1 V` �� 0 <br /> J O <br /> ( pU Q-v C,, IA,,ociated Permit(s): Expiration: ,2- <br /> 5 l <br /> �GS' O <br /> WORKLOCATION: Q ��°�_ l� `� - 0,Q)9 <br /> tart Date: �\-�"1 l \ Completion Date: <br /> COIN-MOL <br /> 'OIN OL MWER, <br /> QALL (209) 937-3,W.,,6 TO REQUEST A C-09MY, <br /> ATTENTION:Applicant/Contractor-you are responsible to replace all broken,damaged, t <br /> and/or raised sidewalk,curb and utter from score mark to score mark adjacent to the NUMBER� �O LESS THAN�� H�j1RS, �U� ��T <br /> 1 <br /> parcel;remove USA markings upon completion of the permitted work. C10V1 0 72 HOURS��OR I START OF WORr, <br /> I(or we)hereby apply for an Encroachment Permit to carry out the following work: <br /> G Vs y— (C <br /> S'R6w sketch or refer to attached Drawing T <br /> Official Use Only <br /> Base Permit Fee $ 523.00 <br /> Additional Footage Fee $ <br /> Misc. CRS Fee $ 31.3% <br /> Misc. Tech Tom, $ 31112-3 <br /> Misc. $ <br /> Total $ 10 3. 6 I <br /> Special Conditions: <br /> • CaUI for a confivvl number <br /> • Call -vr ihSpectim (Z0Q)63q- 12$2 <br /> • q" - 3 PM res¢ricf ea work <br /> Re.StvYe- to Gll1 ct"darms <br /> A' Cal trans perm It re�L4iWo( <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit, as well as all applicable city ordinances, resolutions, Standards and <br /> 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 <br /> requirements. Failure to comply will be cause for revocation of this permit. Applicant agrees to indemnify and hold the City harmless against any and <br /> all losses, costs, or damages resulting from injury to persons, death of person or damage to property occurring at the site of, or as a result of, work to be <br /> performed under this permit.A certificate of insurance shall be on file with the City Risk Manager prior to issuance of this permit. <br /> IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE <br /> OF A CONTROL NUMBER, THE CONTROL NUMBER WILL BECOME INVALID <br /> AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER. PRIOR TO <br /> ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS Sign <br /> PERMIT,PERMITTEE SHALL CALL INSPECTIONS AT(209)937.8381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE C� <br /> SIGNING. Print C,;'�N� <br />