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JOF-01-2010 THU 12:09 PFI P1itE' S TOWING SERVICE FAX No. 2094P;�4999 P� 001
<br /> CITY OF STOCKTON ? 2- G 34
<br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RICHT-OF-WAY
<br /> Applicant's game t L �l td i eats a' j APPROVED: BY THE PUBLIC WORKS DIRECTOR
<br /> (Owner/C ntractor) � Subject to the General Provisions and Special Conditions,
<br /> Address E1 # U �Phone �1 70151 C°��
<br /> and all work must conform to the project's approved Storm
<br /> City i tT t_ r State 6A x zip 158,4, Water Pollution Prevention Plan or the most current version
<br /> Location of Proposed Work,ate, 53( d L0+4y�t i 5f" of the City of Stockton Storm Water Pollution Prevention
<br /> Maintenan a Staff guide,whichever is applicable,
<br /> r� gq .Z �r_roizy� 4I !C By Data /r
<br /> Owner/Contractor Address
<br /> Estimated Starting Date . �_ Completion (data L � -mit Expiration Date_„ � } ��
<br /> I (or We)hereby apply for an Encroachment Permit to carry out the following work;
<br /> /�lrfatf t r 1 rt�� We� L. 1 F, ..Fkf C- Oe-'Qt f--/
<br /> lIx
<br /> Ht,,v Ta F f L14 If-A YES 7 t
<br /> ATTENTION.Applicant/Contractor—you are responsible to
<br /> replace all broken, damaged,and/or raised sidewalk, curb and PERMIT FE=E........................... $
<br /> gutter from score mark to score mark adjacent to the parcel; f
<br /> remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $
<br /> Th,,aIo,,o non,md sppiteaat 11,11,11,requests 111, 1$51on 14
<br /> j Sewer Talc $
<br /> TOTAL,DEPOSIT .,,... $
<br /> Building Permit No.
<br /> L a�- ,l>��`�l�� Improvement Flan No,
<br /> Sup. lemental Conditions;
<br /> "4W10PERMIT NOT VALID WITHOUT A
<br /> CON
<br /> T �P NUMBER.
<br /> 4 � CALL (209) 'x'37.9 TO REQU�S I` � CONTROL
<br /> L., Iy rr
<br /> NUMBER NO LESS Tl f+ 24iS, Etta NO!' i;
<br /> 1��^r;}t--Gppi���ggS }0�97g2�HOURS PRIOR TO START itRl{.
<br /> Show el:atch obove or refer to drAwing aubinitte 3
<br /> IMPORTANT,, Applicant heraby agrees to comply with all provisions of this permit,as well as ail 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 most 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 lasses,costa,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,workto be performed under this parmlt,A certificate of insurance shall be submitted to the City Risk
<br /> ivlanager 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 45W CONTROL NUMBER,(PON CAPITAL IMPROVEMENT PROJECTS OR
<br /> SUBDIVISION iMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(200)937.9411 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)937-8361.
<br /> READ GENERAL PROVISIONS 00 THE REVERSE.SIDE OF THIS PERMIT BEFORE SINNING.� '�Lr�.tj� k3el Y J
<br /> Signed: - 'c ! — Phone
<br /> 1$'-Permittee(white) 2nd-inspection(pink) Std-File(yellow) rith-Finance(white)
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