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67881 <br /> PUBLIC <br /> CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT <br /> AA A��PPLLI��CC�ATION FOR(ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name( li)�� U�I,�Ih�VWOL1 (Date U APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner ontra r) (��/� ©�,�,( Subject to the General Provisions and Special Conditions,and all <br /> Address sYt —w 1-4 i.<� Phon /^ work must conform to the project's approved Storm Water Pollution <br /> City �t I�tnJ� State� Zip Q S2,l J Prevention Plan or the City of Stockton Storm Water Pollution <br /> �P•P Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc. eta 1 a Otte t <br /> Owner/( E�Address Shcw,, � Ck <br /> By Date <br /> M_ - <br /> Estimating Starting Date Completion Date /j;�� Permit Expiration Date <br /> I (or We) hereby apply for an 1rncroac ment Permit to carry out the following work: Zh j 1 j <br /> e-i11 4- <br /> Llne 6 (We-1 i la-G ► hs r� l <br /> Z 30 <br /> The above named applicant hereby requests permission to- �— <br /> ' » PERMIT FEE............................$ <br /> >1id�� ���C t� �O Additional Footage Fee............ $ <br /> tvnY K—�ICGti j S f /`���CLL.` Trench Fee............................... $ �- <br /> 1 Sewer Tap Deposit.................... $ �— <br /> TOTAL DEPOSIT.........$ �3 <br /> all <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> See <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 indemnity 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 CAC(2-'09,)937-8366 FO A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE STARTK R TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT.IF WORK DOES NOT BEGIN 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.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Signed ) I Phone: <br /> 1st-Permittee(white) 2nd-Inspection(pink) 3rd-File(yellow) 4th-Finance(white) <br />