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ITV fv1C CTA��Tr1N <br /> PUBLIC WORKS DEPARTMENT s <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name G'tAtJT�-�- CUwVVT1Date APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> Address 301-4 Y-i P-0Sri 1bD Phone (91-6wit-Cup Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City R,Aj.W o cpfta-' A State O_Zip�feala_ Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. ZOS 290B L'( <br /> Hof the City of Stockton Storm Water Pollution Prevention <br /> — Maint5pyice Staff Guide, whichever is applicable. <br /> Owner/Contractor Address -501-+Kok,),00-r,- " STI 100 By Date <br /> Estimated Starting Date r���pa Completion Date 6 ffi Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: 60N bl�-, -3 Eylkf n4�) <br /> (,,,r2b1WbW ATG - NIP NyrLi-IZ-I&X-, W 614:.S J4 0-1 .F &M 91:-�-PAVE <br /> [b-ili,) _n-F W&L_L�& A.nAcHLD Frio <br /> ATTENTION:Applicant/Contractor-you are responsible to <br /> replace all broken,damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ S� <br /> gutter from score mark to score mark adjacent to the parcel; 'Z <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $ 3 <br /> The above named applicant hereby requests permission to <br /> Sewer Tap Deposit.................. $ <br /> TOTAL DEPOSIT ...... <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT NOT VALID WITHOUT A <br /> aON*rROL NUMBER. <br /> :ALL (209) 937-M TO REQUEST A CONTROL <br /> .;UMBER NO !.ESS THAN 24 HOURS, BUT NOT It, <br /> `CCFSS OF 72 HOURS PRIOR TO START OF WORK. <br /> Show sketch above or refer to drawing submitted --^-••^---�----- w_ -w <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 /> 1F 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 /> f <br /> a' �`6� <br /> Signed: Phone: C11cp 00w— <br />