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CITY OF STOCKTON 71668 <br /> PUBLIC WORKS DEPARTMENT <br /> n APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> M5 <br /> Applicant's Name 477 Date "/J_ APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) Subject to the General Provisions and Special Conditions, <br /> Address Z At'll- 9.1 Phone '/?y Y3s?' <br /> and all work must conform to the project's approved Storm <br /> City oe;�Ckfurr _State r–lf Zip r?rZ%U 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. gem f a/ a/ GrIC Maintenance Staff Guide, whichever is applicable. <br /> —610 r <br /> Owner/Contractor Address By 144AqDater <br /> Estimated Starting Date Z"- Z�� Completion Date `7�S c� Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: T r <br /> ��nc luinl�i 4VC,,Y 53 f'7 /af rCy C'krSf/ j /Cv t7�JojS. Y« �rfl 6c in luras, <br /> Lmc opr 1)y Al Srn nt7/f• /V2<� {a in��fl�p7f �tl1fs hc/z Ja-- �0 C'xis�izS Urr�t►�/�v, <br /> &J,44l / l /Co,F�� c)d 7e-/,z, Te <br /> qLr 6v2 CaWSc <br /> /poin�. <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 /> (j /�ffz ( TOTAL DEPOSIT ...... $ <br /> 5�4 Building Permit No. <br /> Improvement Plan No. <br /> Ut ZCJ- Supplemental Conditions: <br /> PERMIT NOT VAUD WITHOUT A <br /> CONTROL NUMBER. <br /> 4- /0701e c+ L r ti fs�{ CALL (209) 937.8386 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 refer to drawing submitted CVIS 1 ROL# <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 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: V <br /> -Permittee (white) 21d -Inspection (pink) 3" -File(yellow) 41° -Finance (white) <br />