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iCITY OF STOCKTON 73493 <br /> DEPART <br /> PUBLIC WORKS DEPARTMENT _ __ <br /> APPLII:Prlfd lOFVR tlV l.liUAl+f1MtNI UN Pi,I E{Lll: FiloM1-UY-WAY � SVfji <br /> Applicant's Name <br /> �} J� „Q ) E/� Q ate X21 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Gontractor)C� 07 1� Subject to the General Provisions and Special Conditions, <br /> Address on �r �' Phone and all work must conform to the project's approved Storm <br /> State Water Pollution Prevention Plan or the most current version <br /> C1_ .10 \ Gi Zip q 5265 <br /> City ��,/ of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. �l¢S -�A'� /c81` Maintenance Staff Guide,whichever is applic`a'ble. <br /> .c.,) ' <br /> By ate <br /> Owner/Contractor Address IZo Permit Expiration Date L;11-- l <br /> Estimated Starting Date ICompletion Date �— — <br /> I (or We) hereby apply for an Encroachment Permit rry out the following work: <br /> kZ010 1! <br /> SZ3 <br /> ATTENTION: Applicant/Contractor—you are responsible to 2 3� <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE................ $ <br /> gutter from score mark to score mark adjacent to the parcel; ee .......... $ <br /> remove USA markings upon completion otthe permitted work =tt <br /> C GThe above named applicant hereby requests permission to: ......•........ $ <br /> C 7 6 4 <br /> TOTAL DEPOSIT ...... $ ✓17v <br /> Building Permit <br /> n Improvement Planan <br /> No. <br /> Supplemental Conditions: <br /> PERMIT NOT VALID WITHOUT A <br /> V CONTROL NUMBER. <br /> / �pt CALL (209) 9378388 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT Ih <br /> Z D EXCESS OF 72 HOURS PRIOR TO START OF WORK <br /> CONTROL# <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 /> ay to the City its actual cost for removal and proper replacement of any item which <br /> Standards and Specifications currently in effect, and to pthis <br /> tdoes not meet the above he City harmless againstanyand all tlo losses,costs, or s. Failure to comply <br /> resulting from iinjuill be cause for lry toon fpersons death Applicant <br /> person rordamage onproperty old <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 DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL ER,THE CONTROL NUMBER WILL <br /> BECOME0INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER. (FOR CAPITALL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(2D9)937-8411 FOR SPECIFIC <br /> INSTRU THIS PERMIT,PERMITTEE SHALL CALL CTIONS PRIOR TO THE BENNING OF Y W RK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE <br /> SIDE <br /> 1. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. 467 /,��yM�/p <br /> Signed: V�' VCUG"" � Phone: "_ <br /> V' -Permittee (white) <br /> god -Insoection (oink) aro-File (yellow) 411 -Finance (white) <br />