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V, <br /> CITY OF STOIC ON <br /> PUBLIC WORKS DEPARTMENT 68948 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> MM5 <br /> t trz+-t G t?' /.VC /ilk. <br /> Applicant' e t-I f lG E- tvG Aj G+-� Date �-�'"o Ll APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> {Cwn Co tracto Subject to the General Provisions and Special Conditions, <br /> Address -t' + < Lfl Phone *to %ate S"t and all work must conform to the project's approved Storm <br /> City ' i'State ZipWater Pollution Prevention Plan or the most current version <br /> Location of Proposed Work,etc. ;� rrv�.+-e � ytfl� <br /> of the City of Stockton Storm Water Pollution Prevention <br /> Mainte ce Staff Guide,whighever is applicable. <br /> caner ontractor Address �`A�'s tc X5 40OV6 8y Date 7- <br /> Estimated Starting Date_�7 d l Completion at Permit Expiration Date �!f <br /> r <br /> Ila <br /> I (or We)hereby apply for an Encroachment Permit to carry out the following work: za " <br /> 11,1 gl4`rrd Al <br /> ATTENTION:ApplicanttContractor—you are responsible to <br /> replace all broken,damaged,and/or raised sidewalk,curb and PERMIT FEE ...................... $ t� <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 Hamad applicant hereby requests permission to: <br /> Trench Cut Fee......................$ <br /> Sewer Tap Deposit .................$ <br /> 1 <br /> TOTAL DEPOSIT...... $ <br /> ~ � <br /> Building Permit No. <br /> Improvement Plan No, <br /> Supplemental Conditions: <br /> A t <br /> 421Z4,(Aff Af t4— <br /> Show sketch above or refer to drawlntt 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 ermit. <br /> j PERMITTEE SHALL CAL t�29;37-812;��FA CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS,PRIOR <br /> j TO THE START OF WO NY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT. IF <br /> WORK DOES NOT COMMEIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER 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{2119}937-6411 F7ECIFIC <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> i <br /> r 4,>/4 72157 <br /> Signed: Phone: <br /> 1st-Permittee(white) 2"d--Inspection(pink) Std-File(yellow) 41h-Flnance(white) <br /> Zooln H111u`HOVIA E6906ZL9T6 XVA of:9T tr00910£!TT <br />