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CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT 7 1 8 8 0 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Conlrac f �. <br /> Address �" 64 `,,/,3'® ` Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City /-'14-1C0& State Zip �� 0 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. Mainten ce Staff Guide, whichever is applicable. <br /> C..-Lr%?,/j 1:�/�', G'1'' ��t/, L`'1✓'-��`/�i1 L`-Z�i�✓r� `��'- t°�'-s,.�%/�',rp��'"�iJ ~ - // <br /> Owner/Contractor Address Vz5 tBy <br /> Estimated Starting Date i�"� �� _ Completion DatePermit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> _ %/tl �� /j /r/r: C_�a° i'_),�L,✓ y'� t t� f .!�;';� i ✓r, f- L` ; { <br /> tJ <br /> / l7 <br /> J.., ,7r M l �f�Ne <br /> ATTENTION: Applicant/Contractor—you are responsible to G <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 /> ` 1J' X) %l �-1.�,�w t !a TOTAL DEPOSIT ...... $ J <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> #,///?,;, 1— <br /> 5�rvkrs /2i4r3 <br /> ?"_"h4§3 9 _ ii 4 6 1aSgEy $ {�,i1' 3d QI{'• / (" �G�� <br /> c <br /> %if,ABER NO LESS AN 24 <br /> Show sketch above or refer to drawng 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 /> J,,5of.,, <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE StQNlA1G._ <br /> Signe �;,`: 'Gc t Phony <br /> Ind (-i„L) '2rd _Filo / olln,n1 n�^ Ci.,on�o /nih ita\ <br />