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u CITY OF STOCKTON 69606 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Named <br /> UQVI(.C� e1 l ate fI APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/ ntrac r) f <br /> Address ��Ltd Phone--209 /A7(J Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City �for_!c�r3�J State CA— zip9S-Z17 Water Pollution Prevention Plan or the most current version <br /> of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. _5/' ac z a Re r31 0.0 Maintenance Staff Guide, whichever is applicable. <br /> .�i170 S C lure oft SA.L2� <br /> Owner/Contractor Address By C ! Date <br /> Estimated Starting DateS Completion Date I 1 ` (7 Permit Expiration Date — <br /> 1 (or We) hereby apply for an Encroachment Permit to carry out the following work: _Ti"lS Aa el 0-4.<j- UkLtiI u �L�! <br /> 0(l f� IALee ' t)h If S t e I-ri•J r fS(,r:� - o wa-g, <br /> 1►7 H-/ Ot�sS etKa Awltve�e_yT <br /> �n s�� �c7 y i t� � �� � fin/Gl�e-t�v� ��C/ �e•-•�cc. 1 �t�/i2c- d��SGS f/�ins <br /> ATTENTION:Applicant/Contractor—you are responsible to �7 <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ L (? <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 /> Co' Sewer Tap Deposit.................. $ <br /> A/� -�"�- 4 A, TOTAL DEPOSIT ...... $ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT NOT VAUD 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# S'S 0z?DO <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— Phone:(,20144o77 104(o <br /> 1sl-Permittee (white) 2nd-Inspection (pink) 3rd-File (yellow) 41h-Finance (white) <br />