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CITY OF STOCKTON <br /> ZM PUBLIC WORKS DEPARTMENT 06 3 4 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> AAppplicants Name.. 2r 0,e -�ME•!�✓�T/o.t<�1GDate IIS -27— APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (OwnedContractor) Subject to the General Provisions and Special Conditions,and all <br /> Address LrL d oc Phone !`r/6` work must conform to the project's approved Storm Water Pollution <br /> City eo- 404.14 State Zip s3 G 77 P Prevention Plan or the City of Stockton Storm Water Pollution <br /> Prevention Mainte ce Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc._ / e f?x/.Sti G s <br /> /YZ <br /> Owner/Contractor Address c/ By Date <br /> Estimating Starting Date G/f / ZcldZCompletion Date 0 rmit Expi tion Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: �L+�S7rPL <br /> The above named applicant hereby requests permission to• <br /> PERMIT FEE............................$ <br /> Additional Footage Fee............ $ <br /> f Trench Fee............................... $ <br /> Sewer Tap Deposit.................... $ <br /> TOTAL DEPOSIT.........$ <br /> Building Permit No. <br /> Improvement Plan No. <br /> up iemental Con itions: <br /> K� � �� Cald►I11QCl�1fUl1 � ! �1LvILj <br /> KA7 <br /> Show sketch above or refer to drawing submitted t .,am . <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 does <br /> not meet the above requirements.Failure to comply will be cause for revocation of permit.Applicant agrees to indemnify and hold the City <br /> 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 <br /> of,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 <br /> of this permit. <br /> PERMITTEE SHALL CALL(209)937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT.IF WORK DOES NOT BEGIN 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 <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERM!ps ORE SIGNING. <br /> Signed fl Phone: <br /> 1st-Permittee(white) 2nd-Inspection(pink) 3rd-File(yellow) 4th-Finance(white) <br />