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CITY OF STOCKY N 69805 9! ,- l� PUBLIC WORKS DEPA TMENT DOS APPLICATION FOR ENCROACHMENT O PUBLIC RIGHT OF-WAY E �cd�%3jrjq �► LO—7-05' APPROVED: BY THE PUBLIC WORKS DIRECTOR Appiicant's Name Date (Owne ontracto q4 7Z9 37?'q Subject to the General Provisions and Special Conditions, Address Phone and all work must conform to the project's approved Storm i State GA Zip 4'STAl Water Pollution Prevention Plan or the most current version City-� NT c(,_to�E of the City of Stockton Storm Water Pollution Prevention Location c Proposed Work, etc. Z 41r C G e-, r- Maintenance Staff Guide,whichev is applicable. C I N Owner/Contractor Address CE A PYIE y ate 'iY/-f--O Permit Expiration Date 1 `O Estimated Starting Date Completion Date I (or We) hereby apply for an Encroachment Permit to carry out the following w rk: G rr vim✓ 141A7C-,F ry w G L '" —r L 7 '27/i E Srz,-, iM I� ATTENTION:Applicant/Contractor-you are responsible to replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE.......................•• $ gutter from score mark to score mark adjacent to the parcel; . remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $ i li The above named applicant hereby requests permission to Sewer Tap Deposit.................. $ � -6� A-T 74-G H TOTAL DEPOSIT ...... $ II �/ Building Permit No. Improvement Plan No. i, Supplemental Conditions: 4 PERMIT NOT VAUO WITHOUT A CONTROL NUMBER. CALL (209) 9374366 TO REQUEST A CVJROL NUMBER NO LESS THAN 24 HOURS, BUT NOT IN EXCESS OF 72 HOURS PRIOR TO START OF VVORK .i CONTROL# E; Show sketch above or refer to drawing submitted IMPORTANT: Applicant he agrees to comply with all provisions of this per. it, as well as all applicable city ordinances, resolutions, Standards land Specifications currently in effect, and to pay to the City its actual cost for removal and proper replacement of any item which does not meet the above requirements. Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnify and hold the City harmless against any and all losses, costs,or damages resulting from injury to persons, death of person or damage to property occurring at the site 4f, or as a result of, work to be performed under this permit A certificate of insurance shall be submitted to the City Risk Manager prior to issuance of this permit. IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITTEE SHALL CALL-FOR ANEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY R EQUIREWNSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937-8381: READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. 4,4Z, r v�/ Signed: Phone: 'N Z?Y 1p 7 15'-Permittee (white) 2nd-Inspection (pink) 3rd-File(yellow) 4th-Finance (white) 6