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•; '03/2:6/2003 WED 15:57 FAX 91654356 Z002/002 <br /> CITY OF STOCKTON v <br /> PUBLIC WORKS DEPARTMENT <br /> =05 y� APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name StTA�t'/ 1f��?/�' t/77 Date �f 1B►�CZ3 APPROVED:BY THE PUBLIC WORKS DIRECTOR <br /> ( caner/Contractor) - <br /> y �� Subject to the General Provisions and Special Conditions,and all <br /> Address t!�_ /_(,/• �� f1�T i4 i//) Phon( work must conform to the project's approved Storm Water Pollution <br /> City Si�GI�t.N State 6- Zip5934/ Prevention Plan or the City of Stockton Storm Water Pollution <br /> f _ Prevention Maintenance Staff Guide,whichever Is applicable. <br /> Location of Proposed Work,etc. �.� i✓�.57` 614/ Rl7ER <br /> `J j'JG%Ori/ 4-A <br /> DOwner/Contractor Address L. AV22/0&9-.,,ftt <br /> te <br /> e <br /> QEstlmatin Starting Date �AJDDComplotion Date Expiratlon Dat15 <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: OF <br /> -3 "W&- TYE SII ;I,/ t'-/w PKp i y <br /> oL <br /> lag <br /> The 9bovq namgd Spplic,nt horpby raly95t5 permi55iOn to <br /> 10 PERMIT FEE............................$ <br /> Additional Footage Fee............$ <br /> Trench Fee...............................$ �� a+S�/✓ <br /> Sewer Tap Deposit $ <br /> TOTAL DEPOSIT---------$ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <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 /> 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 INSPECTION$,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 GALL.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 <br /> TTTHIS PERMIT BEFORE SIGNING. <br /> Signed:__ Phone: <br /> 1st-Permittee(white) 2nd-In5pectlon(pink) 3rd-Fila(yellow) 4th-Finance(white) <br />