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CITY OF STOCKTON 69981 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name Date 3 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> Address %-A �.\c,�c_ " Phone%'"1A01- 04� Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City 'Q1>,r,,k1,o State(_A —Zip `151,-4.o Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. �� Z� o; 2.ria& of the City of Stockton Storm Water Pollution Prevention <br /> Maintenance Staff Guide, whichever is applicable. <br /> Owner/Contractor Address 1 ���.crc. 0-A By Date <br /> Estimated Starting Date `coo Lpo44 Completion Date Air; ?moi. Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: .i r�SSG.\\car.inn Gt cv� <br /> C`r1t7c\� mac. n t �i,�.\ o.,�c� G.� �t Q.n C v VY1 Q.1�► C`.1 C'♦v�R Z t i` 1p c-rr i% <br /> ATTENTION:Applicant/Contractor–you are responsible to <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ 3LO <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 ...... $ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PER',1V ZOT►V_L!D of- i ��'1 A <br /> CALL (209) 93743333 TO REQUEST A CC,4TROL <br /> NUI.`BER NO LESS TW-V 24 H=RS, BUT XOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF 4VORIC. <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 BEFORE SIGNING. <br /> Signed: Phone: <br /> 1St-Permittee (white) 2nd-Inspection (pink) 3`d-File (yellow) 4th-Finance (white) <br />