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CITY OF STOCKTON I4 <br /> PUBLIC WORKS DEPARTMENT 68669 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC�RIGHT-OF-WAY <br />€ Applica*NameW00AW4rJ o ,Y ' Date APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Ownsctor fl 3 Phone 70] Subject to the General Provisions and Special Conditions, <br /> Addresand all work must conform to.the project's approved Storm <br /> City X,-o 1/i s' State 0-^A Zip .97 Water Pollution Prevention Plan or the most current version <br />'! Location of Proposed Work,etc. 12 0_7_ l`7 U Y'D ra S�, of the City of Stockton Storm Water Pollution Prevention <br /> Mainte nce Staff Guide,whichever is applicable. <br /> CA- , ./I'! W'—3 Mee 1 f �IRf_c ' r` �] <br /> t <br /> Owner/Contractor Address �.Q,ac}-3 3 fl,%y l/�7�.C4 By i i ©ate ! -� <br /> Estimated Starting Date Completion Date 6,19- b, 1i Permit Expiration Date <br /> I (or We)hereby apply for an Encroachment Permit to carry out the following work: it r• treWe <br /> O h r s <br /> it <br /> ! <br /> ATTENTION: ApplicanVContractor-you are responsible to <br /> replace all broken,damaged, and/or raised sidewalk,curb and PERMIT FEE ...................... $ 30 04 <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 /> 1+ <br /> The above named applicant hereby requests permission to: 'i <br /> Trench Cut Fee..,....................$ <br /> r. •-"rc) C -rt�(�1 try Sewer.Tap Depositr <br /> ly <br /> SG(L;,,r T7-�.cL F.' a TOTAL DEPOSIT ,.... $�^ ✓l/ <br /> y !i <br /> Building Permit No. <br /> Improvement Plan No. <br /> f <br /> Supplemental Conditions: A5 ,, <br /> VIE <br /> DD <br /> JUL 2 0 '2004 <br /> ENVIRONMENT HEALTH <br /> Show sketch above or refer to drawlnp submitted PERMIT/SERVICES <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 forlremovall and proper replacement of any item which <br /> dotes not meet the above requirements. Failure to comply will be cause for revocation oflthis perrmit. 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. Ij <br /> PERMITTEE SHALL CALL(209)937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS BUT NOT IN EXCESS-OF 72 HOURS,-PRIOR... <br /> TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THISOERMIT.. .IF <br /> WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMSEk-WILL BECOME- <br /> INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER. (FOR CAPITAL-IMPROVEMENT PROJECTS-OR SUBDIVISION <br /> IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT'(209)937-8411 FOR SPECIFIC <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. . <br /> Signed: ,�rJ0 Phone: <br /> 1 S`-Permittee (white) 2nd-Inspection(pink) 3rd File (yellow) 4th-Finance (white) <br />