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CITY OF STOK O.N <br /> PUBLIC WORKS--DEP RTMENT 2 <br /> 91 <br /> APPLICATION FOR ENCROACHMENT IN,PUBLIC RIGHT-OF-WAY .� 3 <br /> i 16 *7-1S-a APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> Applicant's Name �zy� *"" ���� ate _._� <br /> {Own Subject to the General Provisions and Special Conditions, <br /> Addressi_�' S7Qi� _. s'lione'�6� 72`�S/`C� 1 <br /> and all work must conform to.the project's approved Storm <br /> City State� Zip 9 3 Water Pollution.Prevention Plan or the most current version <br /> of`the4City of Stockton Storm Water Pollution Prevention 1 <br /> Location <br /> of Proposed Work, etc. +Og Z 3/� Maintenance Staff Guide,whichever is applicable. <br /> -7`7 <br /> wn Contractor Address !� r l$�� <br /> a <br /> IE <br /> 4 * r ro By Date. <br /> Estimated Starting Date -� ompletion'clate —3l �� Permit xpiration Date <br /> (or We)hereby apply for an Encroachment Permit^to carry out the:.followingork,•, . <br /> k1 11b E <br /> 61, `.` y rw wr <br /> is <br /> i <br /> ATTENTION:Appllcan.VContractor—you are responsible to <br /> replace:all broken, damaged, and/or raised sidewalk, curb"and . P RMIT;FEE........................... $ <br /> gutter from score mark to score mark adjacent Wthe parcel; <br /> remove-,USA markings:upon completion�of the:perrnitted,,work. . Additional Footage Fee........... $ <br /> 'r The above named applicant hereby requests permission to; Sewer er 1' p Deposit.................. <br /> iv �} TOTAL DEPOSIT ...... .$ <br /> ci&a,+1c� �NZ �1'y <br /> (? B Wilding:Perrnit No:. <br /> Z 3�� .Improvement Plan No. <br /> i v S pplemental Conditions: <br /> it Af Ct4vv, ter <br /> �� � � nr3�r. .Nwr�. �•�Q, <br /> PERMIT NOT VALID WITHOUT A <br /> CONTROL:NUMBER. <br /> I` CALL='(209)1374M6 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> s EXCESS OF.72.HOURS PRIOR TO START OF WORT(. <br /> CONTROL# <br /> i Show'sketch above or refer to drawin submitted <br /> IMPQRTANT: Applicant.hereby agrees to comply°witFi all provisions'of this p� -mit as well assail applicable city ordinances, resolutions, <br /> Standards and Spe°cifications-currently in effect, And to pay to the City its actu.l'cost for reiFioval"and'proper replacement of any item which <br /> does not meet the above requirements:Failure�to comply will be cause for re.ocation of.thls permit..Applicant agrees to indemnify and hold <br /> the City harmless against any andiall losses, costs;-or damages resulting fro :`injury:to-Qersons;death'of.person or damage to property <br /> occurring at the site of, or as a result of,work to be pertormed';uncfer'this per it:A certificate of.insurance shall be submitted to the City Risk <br /> Manager prior to issuance of this permit. <br /> . , <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 CONTR L NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL.CONTACTTHE ASSIGN D`CT Y PROJECT�ENGINEER AT(209)937-8411 FOR SPECIFIC <br /> INSTRUCTIONS:PRIOR TO THE iBEOINNING:OF.ANY WORK.)`PRIOR'TO'AN 'REQUIRED'INSPECTIONS,AS IDENTIFIED ON THE REVERSE <br /> SIDE O !THIS PERMIT,PERMITTEE SHALL CALL(209)937-8381 s <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE'OF THIS PERMIT BEFORE SIGNING. <br /> 004, <br /> Signed: bedo�,_ Phone: <br /> I� irl-Permittee.(white) 2nd-inspection (pink) 3rd-File(yellow) 4th-Finance (white) <br />