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CKTON <br /> S CITY OF STDEPART 71094 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Namei"IAyQAAx4 C-t W'11I ] Date APPROVED : BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/C ntracto[) ^ ,� 1 f <br /> Address 1i�1 ShAW Q-OA.� Phone c4Y9 -W Subject to the General Provisions and Special Conditions , <br /> LL ���� ���� and all work must conform to the project's approved Storm <br /> City SRu�Utn State C/� Zip 0( 5)L \ 5 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 . S P,woAlc Cld)a.(Qt<°{'+o Mainten ce Staff Guide, whit ever is applicable . <br /> u5t) St�cY.hm <br /> 1 f� �d <br /> Owner/Contractor Address g UW+1'Utn,t �' �B/y Date <br /> Estimated Starting Date �j - --(a -0 Completion Date �� " - 0 'd Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work:f L <br /> ITdVTAVLCDi CNtR favuVI 0� � 5 l�F �' h $ �1 Iu CO (ICG { fDI � SQtM �1 �' <br /> ( V1 Ct S n H—1 f-op wa I wry l �s 4 a <br /> 5 D pi e vxeY� SkvPe� Ska V+y o-r\ S av ffn Sid e <br /> ATTENTION : Applicant/Contractor — you are responsible to <br /> replace all broken , damaged , and/or raised sidewalk, curb and PERMIT FEE . . . . . . . . . . . . . . . . . . . . . . . . . . . $ J [ <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 . . . . . . $ �� o <br /> Building Permit No . <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> qic� tr <br /> iR,�'1- O..� G f ' 3A0 he <br /> PSG nr' <br /> ®P��7r <br /> tAro �Llk jod 51y1f , aa .( or, // G.i,. lc f4AI/ Srald"arI <br /> PERMIT NOT VAUD WI I HOOT (Af, <br /> CONTROL NUMBER. <br /> CALL (209) 937-83435 TO REQUEST A CO1IROL <br /> NUMBER NO IC$S THAN 24 HOUR%S RUT N IF <br /> EXCESS OF 12 HOURS PRIOR TO SlAFIT OF 41104sfC. <br /> CO��TROL� _ <br /> Show sketch above or refer to drawing 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 /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT B E SI G. <br /> 20A <br /> Signed : Phone: �wj7 -) ooh <br /> 1s' - Permittee (white ) 2nd - Inspection ( pink) 31d -File (yellow) 411, -Finance (white ) <br />