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CITY OF STOCKTON 67162 1 C6? <br /> i <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY ' <br /> e Applicant's Name <br /> `j"(ri, Dale 'L ��- APPROVED: BY THE PUBLIC WORKS DIRECTOR + <br /> (Owner/Contractor) q L T Subject to the General Provisions and Special Conditions,'and all <br /> Address-1�`� GIiYLK- wQS�i CI r. a.lL phone�� �3�'US_! ork must conform to the projecrs approved Storm Water Pollution <br /> GQ Zip 520 prevention Plan or the City of Stockton Storm Water Pollution <br /> City Slate Prevention Maintenance Staff Guide,whichever is applicable. j <br /> Location of Proposed Work,etc._ O°`q ''"'r rt <br /> k -f <br /> aZ o z_ <br /> Owner/Contractor Address "� By Date -5' <br /> ,> <br /> Estimating Starting Date a�+' Completion Date S t aL Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work:._!.;4gn:Rr0 <br /> I', a off'. 't ` �l ib4 �1�� `�•-�-•k_a_ I�.i <br /> K, <br /> The above named applicant hereby requests permission to- •'• 0 0 <br /> PERMIT FEE............................$ <br /> Additional Footage Fee.-........ $ <br /> Trench Fee................ .......... $ t <br /> r Sewer Tap Deposit:..............:.:.. $ • $Y <br /> K TOTAL DEPOSIT.........$ Z 8, <br /> C C� Building Permit No. <br /> Improvement Plan No. ' <br /> Supplemental Conditions: <br /> . �GNK�tOL iC!!//t1r►15 Loa fSLrA �� Y� ,I <br /> Show sketch atmve or refer to drawing subm%led <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 does <br /> not meet the above requirements.Failure to comply will be cause for revocation of permit.Applicant agrees to indemnity and hold the City <br /> 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 <br /> of,or as a result of,work to be perforated under this permit.A certificate of Insurance shall be submitted to the City Risk Manager prior to Issuance <br /> of this permit. <br /> t M <br /> PERMITTEE SHALL CALL(209)937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT.IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL JI <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 <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) f. <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THI PER T <br /> Signed: Phone:2-M 7 <br /> tst-Permittee(white) 2nd-Inspectlon(pink) 3rd-File(yellow) 4th-Finance(white) <br />