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CITY OF STOCKTON 7 1 9 2 3 <br /> S •PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's NamAAvangej GeOEnV ymrAep&J Date e'L IV APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/ Subject to the General Provisions and Special Conditions, <br /> Address Sk4W phone and all work must conform to the project's approved Storm <br /> Cit35 in State Zip q rj-2l Water Pollution Prevention Plan or the most current version <br /> Yof the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. W iti'w Ciy o-F S+25-Ir4010, Mainten��ce Staff Guide,whichever is applicable. <br /> Ole <br /> r ._e r, /s fYt ufi — B /�/1�/I'll ate ��17_/U <br /> Owner/Contractor Address !bol Tk tN eik R 0a d / y�-o� 4 O <br /> Estimated Starting Date S 10 1 b _ Completion Date six /0 Permit Expiration Date_ <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: Ihs-IA11cLir'oK of <br /> t rthq wCU iikin Ake_ 9+9ck-* ROVV pn -FhP Casa 5ik r i oa <br /> rh t. h <br /> a e o ( TiN / KTIt i u• <br /> S7 <br /> I N <br /> O` <br /> ATTENTION:Applicant/Contractor—you are responsible to <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ 73 Z <br /> gutter from score mark to score mark adjacent to the parcel; 3 <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee .......... $ <br /> FT,emed applicant hereby requests permission to Sewer Tap Deposit.................. $hed G��avyftl+ TOTAL DEPOSIT ...... $ Z <br /> `f Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT NOT VALID WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 937-8388 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 /> Show sketch above or rater m tlmwing submitted CONTROL# <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 indemnity 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 THIS PERMIT,PERMITTEE SHALL CALL 209) RK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE <br /> SIDE <br /> 1. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING, <br /> Signed: a /AN� u 1— <br /> Phone: Ib l ro4� <br /> no- ink 3`d-File(yellow) 4'h -Finance (white) <br /> 1s�-Permittee (white) 2 Inspection (pink) <br />