Laserfiche WebLink
CITY OF STOCKTON <br /> f <br /> PUBLIC WORKS DEPARTMENT <br /> Gf"L'APPLICATION FORENCROACHMENT ON PUBLIC RIGHT OF-WAYOR I <br /> RIGHT- <br /> 'Pk' <br /> tz17 $a,!✓rce3 CO✓ CCow�.x.r�or1 <br /> Applicants Namer� `f1� ' 1'�'^S 13�K, �o'Dare //���oo/ APPROVED BY THE PUBLIC WORKS DIRECTOR <br /> ' ( wnerlContractor) <br /> l6f$� Subject to the General Provisions and Special Conditions,and all <br /> Address 7.10 t1k5{ Swid� k icor _Phone 2-91- 15 -7 work must conform to the project's approved Storm Water Pollution <br /> 1 City Co/"'�jea.. State 2 L-- Zip 9Z--Z-3(, Prevention Plan or the City of Stockton Storm Water Pollution Prevention Maintenanc Staff Guide,whichever is applicable <br /> Lroc/ation of Proposed Work etc C<"e,-- �&✓ Cvt <br /> Owner/ ontractor ddress ?_PO t,Jc sir S"� 6'_' - B Date <br /> Estimating Starting Date 1 14 A6>01- Completion Date //?- 2 rmit Expiration Date <br /> 1 (or We) hereby apply for an Encroachment Permit to carry out the following work PL/5 A Cevre)be— <br /> horin 5 (PH-4. 70 to �'cn-be�' eine] bol-,do s�✓ec�ES oI� +.�r.► <br /> ' n S v t✓ GJGI1 ZAT.6 <br /> r <br /> ' The above named applicant hereby requests permission to <br /> PERMIT FEE $ <br /> Additional Footage Fee $ <br /> Trench Fee $ <br /> Sewer Tap Deposit $ <br /> ' TOTAL DEPOSIT $ <br /> Building Permit No <br /> ' Improvement Plan No <br /> Supplemental Conditions <br /> da s%res a-C Pt~r IMI-E1 J <br /> w t tti t1,.i S P��v►�t�t. <br /> �II�-��.a„ r1C�,�r,:f-�i� <br /> Show sketch above or refer to drawing submitted J� 13A11 `34id C k &A. <br /> ' IMPORTANT Applicant hereby agrees to comply with all provisions of this permit,as well as all applicable City ordinances,resolutions, lt� Ci ca i� <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 />?ECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER (FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> UBDIVISION 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 PERMIT BEFORE SIGNING <br /> Signed :2 M,/.J /C1 Phone �b�gl Zg l — f sd <br /> 1st-Permittee(white) 2nd-Inspectkm(pink) 3rd File(yellow) 4th-Finance(white) <br />