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209-234-05313 Line 1 10:00:49 01-18-2008 2/2 <br /> CITY OF STOCKTON 71696 <br /> - <br /> PUBLIC WORKS DEPARTMENT <br /> / APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> C4 <br /> Applicant's Name t'd ol-EarA e"6441C&e 3 _ APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) Subject to the General Provisions and Special Conditions, <br /> Address 1 9q P�•11(WeE_rGC_ s?c� Phone2-0q7-34!06-16 _ and all work must conform to the project's approved Storm <br /> City State Gf} Zip 95 _ Water Pollution Prevention Plan or the most current version <br /> p 2�6 /l� <� s� of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. s cin _ Mainten e Staff Guide,whichever is applicable. <br /> Owner/Contractor Address ByDate <br /> Estimated Starting Date i a n Z Jj t7 Q Completion Date Jan 4=T Permit Expiration Date 12/31 /4 g, <br /> I (or We) hereby apply for an Encroachment Permit to carry out the! following work: nSoi fir^ 'i 10( e,, Ire-n w.t­c7,I <br /> SAr''%1 114". Wi�( be-/}►►`�d,G To L42 T4 /11( 1lQ-(c--r l k/a t^-%/� {�� ,f2 l4 c� <br /> J o ry, �,, ti J G a l , n . St- .1 �JIn c w t ( I h e- D 1",c <br /> I V l _S 1 ct Q L✓�i 'Y . L O G�T b Q l' 1 w S 1'6 C �Q V O 1 rpt l�S fi f 1,,t)-<S. <br /> h8te-- C.-T- sa wl`l) be- ro r e, ash,, IL-1,,_ <br /> ATTENTION:ApplicanVContractor-you are responsible to <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ <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 name applicant hereby request permission to: �— <br /> (1 i nor Av Sewer Tap Deposit.................. $ <br /> t I �- <br /> �! t , TOTAL DEPOSIT ...... $ 5,�'7 <br /> Ah <br /> �( I <br /> n Val(a pBuilding Permit No. <br /> A I I Yw, mprovement Plan No. <br /> f oti.cy I I Qa�ki„� Supplemental Conditions: <br /> i <br /> 10cY�`Tyi^Ch I I ; araf-r „{� <br /> t I Zfb PERMIT NOT MD WITHOUT A <br /> --- CONTROL NUMBER. <br /> -- . — — — — — — — —- CALL (209) 93748366 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> ` L#Show sketc abo e r tete to drawing submitted CONTRO <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 IOR TO A14Y REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE <br /> SIDE OF THIS PERMIT,PERMITTEE SHALL CA L(209)937-8 1. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. // nn <br /> Signed:_ Phon�Z69)6o f"t�-7 i�tt/z_ <br /> I sz-Permittee (white) 2nd-Inspection (pink) 3rd-File(yellow) 411,-Finance(white) <br />