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CITY OF STOCKTON 7 1 0 3 6 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name Mvaftz,�, (;0r <br /> L• tQ%AlkVr.te `•% j - f APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor), ` <br /> Address �_�,}�161,W 1".�!_ Phone x](17 " �00 � Subject to the General Provisions and Special Conditions, <br /> _ and all work must conform to the project's approved Storm <br /> City State—(-�4—Zip Water Pollution Prevention Plan or the most current version <br /> of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. p v ci� Maintepprice Staff Guide, whichever is applicable. <br /> //%Owner/Contractor Address (X2 k;. 41�1�I-niA ,S-;' , S _n L.k,}ZAV,\_ By Date <br /> Estimated Starting Date (, t1 ' Completion Date _ (,01 a .r Permit Expiration Date 7/0 Lr <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> Alvaince-tti-& I-x ri it\ c 1 . <br /> � 'r � ti'+ 'ti� ,� � , n t�. ,v -�'�-- �C .tic;►^ ��{'- <br /> 1 <br /> ATTENTION: Applicant/Contractor—you are responsible to <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ `� �� _C'C <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 ...... $ 33 c <br /> Building Permit No. <br /> Improvement Plan No. <br /> leap. s��- c��t,�.� dh-��►,�`�, <br /> Supplemental Conditions: <br /> War wef/fo 6, <br /> PERMIT VAI UIRHOU1 ,sa, <br /> CONTROL NWABEVC <br /> CALL (209) 937-8,W TO REQOESI r� GONTROL <br /> NUMBER NO ''=,-ESS THt 4'24 FIO<.RSA BUT NOT N <br /> EXCESS OF'72 HOURS i`MOR T`)ST ART OF',OVORK. <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: i L t,7 (� <br /> 1" -Permittee (white) 2110-Inspection (pink) 31"-File(yellow) 411' -Finance (white) <br />