|
�I
<br /> C TY OF STOCKTON
<br /> DEPARTMENT . 76100.
<br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY
<br /> Applicant's Name COI► a[Fct17h ! Ad I� j.Date l2 t APPROVED: BY TH KS DIRECTOR
<br /> (Owner1coactor) f pp
<br /> Address I AFr�,& e.ST4: sre Phone _1� "�SI� Subject to the General Provisions and Special,Conditions,
<br /> �+ ,- and all work must conform to the project's approved Storm
<br /> City �7�Q C� T'D�'I State � _ Zip 2-67 Water Pollution Prevention Plan or the most current version
<br /> of the City of Stockton Storm Water Pollution Prevention
<br /> Location of Proposed Work, etc. �; L{t ci.�tn.q •fit: Maintenanc tall Guide, whichever is applicable.
<br /> Si�LW�f�
<br /> CRT- G��►Ar T I _
<br /> Owner/Contractor Address )7S.C-t�+17`�r-SI~:.Siae�,mrt.C By Date / Z /� /z
<br /> Estimated Starting Date 1,/15A 3 Completion Date 16zt0'111 Permit Expiration Date
<br /> 1 (or We) hereby apply for an Encroachment Permit to carry out the.following work: O 1y/1 Ar'1 c elA,%C,,
<br /> ha bee' ii d ` - b S4Co. Cri v in,/tme TG a
<br /> ytaye- .1 MonllfdWe-11 ,/nW-7,o Qrdor an Su cam►�"r �a� 1�'
<br /> feore- 1-ke- 'W1; .1 ttn !`� 1�cG con_cr�r,✓ ��ClfemarltTo S�rCn2�r�
<br /> slJe W" I , tv►lf b� close wi tk
<br /> ■cru, r.n i uuri �nr
<br /> ATTENTION:ApplicanVContractor—you are responsible to v
<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;
<br /> remove USA markings upon completion of the permitted work. =:tre. $ 3
<br /> ?ho ahave named applicant hereby requests permission to: O$
<br /> TOTAL DEPOSIT ......
<br /> mki"7- j� Permit No. SIV
<br /> Improvement Plan No.
<br /> Supplemental Conditions-
<br /> -,a'
<br /> onditions:
<br /> — �
<br /> • �140UT.A
<br /> r,-. . '�' � qtr 4 g
<br /> r A �. ST A CONTROL
<br /> pe-e-
<br /> I F. M u T-c D--Zol r- �, t� ' s37 TO To a HSS . .
<br /> 5 I!11A ER NO LESS Thi
<br /> i n Slr� r� L �ruE:SS OF 72 HORS PRIOR TO S'�J
<br /> r
<br /> Show sketch above or refer to drawing submitte
<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
<br /> does not meet the above requirements. Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnify and hold
<br /> the City harmless against any and all losses,costs,or damages resulting from injury to persons,death of person or damage to property
<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 j
<br /> Manager prior to issuance of this permit.
<br /> IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OFA 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 CRY PROJECT ENGINEER AT(209)937-8411 FOR SPECIFIC
<br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON_THE REVERSE
<br /> SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937-8381.
<br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING.
<br /> Signed: phoneza9Z �-QSf
<br /> I
<br /> is. o..,—if+,,.,'f...hitnN Ind_!,�,,, r ,, r.,��� ore �or� r., a ..:� erh r_: ....c:. .
<br />
|