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CITY OF STOCKTON 7 1 0 9 8 <br /> DEPARTMENT"" <br /> EPART <br /> ` PUBLIC WORKS DEPARTMENT`J <br /> ML APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's <br /> ��Nam % 1O� aLLn� 1 Dat 1 OF APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> Addres/Cd�c G.WC�E7C.:(.k,,PA Q Subject to the General Provisions and Special Conditions, <br /> / h ne dog 1"I 1170 _'1,187 and all work must conform to the project's approved Storm <br /> City Ston—K-toD State C—A, Zip175ao,41 Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. Su+4-e- S't, of the City of Stockton Storm Water Pollution Prevention <br /> Maint ce Staff Guide,whiche r is applicable. <br /> S13eWe��OnN.�,Pr,rnero�5vtl�re�t�� cash7�n � � <br /> Owner/Contractor Address By Date <br /> Estimated Starting Date h& '7ws Completion Date Permit Expiration Date <br /> 1 (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> tIIoecou nl t �o -11 � 1wKCD(\ <br /> I o 1 ora 11,E 1. <br /> Des-4ro %A-Gc� C It o asb VVAID n <br /> a Hca e'Fa TISMW-_90 OW-8 at\ Ma r <br /> 5. wa11C <br /> ATTENTION:ApplicanVContractor—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 /> (A,e,� avc,�_--44,,(tt(T4�,,(/O/TAL DEPOSIT ...... $ 3�9 <br /> e� Birfdiny Permit No. t^1 ' <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT NOT VALID WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 937.8366 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 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 `�•�s_�-�•�P���aP <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 certi irate 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: Phone: 1?,9`l1_D <br /> rake y,txyd­cL)f blc'-MTwl.--D;rular <br /> Is'-Permittee (white) 2nd-Inspection (pink) 31d-File(yellow) 41h-Finance(white) <br />