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CITY OF S CKTON 71785 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name Date _51U APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> Address 21_7A Ma111 ClS 9W Phone I�—Sd(}'� S Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City ttUi ling-or, �e + State GEA Zip 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. s2_,tz zCI porado c't• Maintenance Staff Guide,whichever is applicable. <br /> GtoC"tl . Ca gS2o& <br /> Owner/Contractor Address I� �01�V1 �� S-�o By Date G <br /> Estimated Starting Date u ?-3 2axompletion Date ULA ok-utib Permit Expiration Date F/I IA13ir <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: 4) <br /> hL <br /> M e� { <br /> r I�. -b <br /> ,(� o fit <br /> ,� �C�S t• , <br /> ATTENTION:Applicant/Contractor—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 /> TOTAL DEPOSIT ...... $ N <br /> +hfiWiiirPermit No. <br /> ---� Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT NOT VAUD VATHOUT> <br /> L CONTROL NUMBER. <br /> :2w CALL (209) 937 TOREQUEST A CONTROL <br /> NUMBER NO LESS 24 RS, BUT NOT li• <br /> IV <br /> etch above or re a EXCESS OF 72 HOURS PRIOR TO START OF WORK- <br /> SON OLS <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: <br /> is;-Permittee (white) 2nd-Inspection (pink) 3rd-File (yellow) 41h-Finance (white) <br />