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CITY OF STOCKTON 67916 PUBLIC WORKS DEPARTMENT M5 APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY Rplicant's Name 5 ?ate e"�`�-03 APPROVED BY THE PUBLIC WORKS DIRECTOR wner/Contractor) / Subject to the General Provisions and Special Conditions,and all Address 0/ Phone work must conform to the projects approved Storm Water Pollution City. SlGr5�7 �Od1 State Zip d7D Prevention Plan or the City of Stockton Storm Water Pollution /mow � eoPrevention Matntenan a Staff Guide,whichever is applicable Location of Proposed Work etc _, .S Owner/Contractor Address , e-o B Date Estimating Starting Date Completion Date rmit Expiration Date (or We) hereby apply for an Encroachment Permit to carry out the following work �X d w X141---g 11�71slvor h- r-� The above named applicant hereby requests permission to PERMIT FEE $ Additional Footage Fee $ Trench Fee $ Sewer Tap Deposit $ TOTAL DEPOSIT $ Building Permit No Improvement Plan No Supplemental Conditions Show sketch above or rotor to drawing submitted IMPORTANT. Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances,resolutions, Standards and Specifications currently in effect,and to pay to the City its actual cost for removal and proper replacement of any item which does not meet the above requirements Failure to comply will be cause for revocation of permit Applicant agrees to indemnify and hold the City harmless against any and all losses,costs,or damages resulting from injury to persons,death of person or damage to property 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 Manager prior to issuance of this permit PERMITTEE SHALL CALL(209)937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL OCECIFIC OME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER (FOR CAPITAL IMPROVEMENT PROJECTS OR D!VlSION IMPROVEMENTS, PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK) READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERWT BEFORE SIGNING f Signed Phone 1st Permittee(white) 2nd Inspection(pink) 3rd File(yellow) 4th-Flnance(white)