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CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT 7 4 4 5 3 <br /> sang APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> =05 t I <br /> Applicant's Name dOtw ( ZrlIawRatOt <br /> APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) 'n ` <br /> Address B37 514gmt Vu Phone o ' �/6 Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City �}�L ,t [' �Sftate �itl'}' / Zip ,�� z 17 . Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. /duT - c oof the City of Stockton Storm Water Pollution Prevention <br /> Maintenance Staff Guide, whichever is applicable. <br /> Ownerl/cWrac or Gress _p�3 '15 ► anw/q �. . ys'� y Wt " A� v Date ( 2" � q( f5 _ . <br /> Estimated Starting Date {� I 20 j' )�la ti tion Date 4L b 21 � 1 ry �Permit Expiration Date 1 V/1.1 <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> S` f 1 -1 ackL v CJS <br /> / <br /> ATTENTION: Applicant/Contractor — you are responsible to <br /> replace all broken , damaged, and/or raised sidewalk, curb and PERMIT FEE , ., .. . . ..11. 0 . ..... .. .. . .. . $ DID <br /> gutter from score mark to score mark adjacent to the parcel; <br /> remove USA markings upon completion of the permitted work. Addjtiotraf oo ate $ } <br /> The above named applicant hereby requests permission to : C1�,5SP�PDeposit: <br /> FT9 $ <br /> epOSl ... .. . ......... ... rr� �76V <br /> TOTAL DEPOSIT ... ... $ 7 ` 7� v/ <br /> Sa- A�1I IV 7' <br /> Building Permit No, <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> � <br /> PERMIT NOT NOT VALID WITHOUT A <br /> aONTROL DUMBER. <br /> !'ALL (209) 937-8388 TO REQUEST A CONTROL <br /> 41JMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> =XCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> Show sketch above or refer to drawing submitted •r/gpl'PYWhI M <br /> IMPORTANT: Applicant hereby agrees to comply with ell provisions of this permit, as well as all applicable city ordinances, resolutions, <br /> Standards and Specifications currently in effect, and to pay to the Cityits 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) 9379911 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) 9374381 . <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFOR SI fll a. <br /> Signed: A Phone: /� 70 1 00 4G`1 <br /> lal -Permittee (white) 2nd -Inspection (pink) 31d -File-(yellow) 4'h -Finance (white) <br />