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CITY OF STOCKTON r ` a <br /> PUBLIC WORKS DEPARTMENTMS O `} <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> M5 '?�A4L_ <br /> Applicant's Name 4WFhAI01i::" CriulA4" NEA'5L Date G7S'�� "� APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> Subject to the General Provisions and Special Conditions,and all <br /> Address 1T7 7 S4 r(L L_> �ti, � Phon, `L,7`t1�r��7-�°e work must conform to the project's approved Storm Water Pollution <br /> Ci State <br /> City C~ Zip �71s Prevention Plan or the City of Stockton Storm Water Pollution <br /> �L r;�.-lL�7y.�1 <br /> e' Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc. IT -.31qf Llrl�- �E+�1FL- <br /> SZc� cA ?� Lf <br /> Owner/Contractor Address 0�//_C4__ 'JrC% By�r`,7 F r eu r} Date 5 3f C <br /> Estimating Starting Date Tay°Z Completion Date , U Permit Expiration Date Q <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: `T �« 54r_tALL,-S Z.� <br /> ,> , ct4, ae- i&IY eok ti c:�La L40 lav AP lel i�f o 2341 &6*4z 4__ .. <br /> The above named applicant hereby requests permission to- <br /> PERMIT FEE............................ $ �"- <br /> Additional Footage Fee............ $ <br /> Trench Fee............................... $ <br /> Sewer Tap Deposit.................... $ <br /> TOTAL DEPOSIT.........$ �40 <br /> Building Permit No. <br /> Improvement Plan No, <br /> Supplemental Conditions: <br /> 1 <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 does <br /> not meet the above requirements. Failure to comply will be cause for revocation of permit.Applicant agrees to indemnify and hold the City <br /> harmless against any and all losses,costs,or damages resulting from injury to persons,death of person or damage to property occurring at the site <br /> of,or as a result of,work to be performed under this permit.A certificate of insurance shall be submitted to the City Risk Manager prior to issuance <br /> of this permit. <br /> PERMITTEE SHALL L(209)937-8366 FO A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE STA,<:OF WOR OR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT. IF WORK DO GIN 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 <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) t <br /> READ GENERAL PROVISIONS ON REVERSE SIDEHIS T BE FO G. <br /> Signed: Phone��^ /)q( <br /> 1st-Permittee(white) 2nd-Inspection(pink) 3rd-File(yellow) 4th-Finance(white) <br />