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10/19/2005 15:52 FAX 510 420 91711- CAMBRIA U002 CITY OF STOCKTON PUBLIC WORKS DEPARTMENT 6 9 7 9 9 APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY M5 e , Applicant's Name r C `I'' ew LJ1, ''. Date '7 _5 APPROVED: BY THE PUBLIC WORKS DIRECTOR (Owner/CQtit actor) tt� ( -C ; .� ,y Subject to the General Provisions and Special Conditions, Address �.. �l k Phone�B yZG g and all work must conform to the project's approved Storm City %M• kr-i State-1,.A Zip _ q6o ss Water Pollution Prevention Plan or the most current version Prop 9 r) C �r of the City of Stockton Storm Water Pollution Prevention Location of Pro osed Work, etc. Gy a Maintenance Staff Guide,whichever is applicable, C,v 1Cs _ECi Owner/Contractor Address ®� v✓t.' Sr..L. 1 yA;04�aew" Date &I—f 2-0 Estimated StartingDate dpi Z� r C6mpletion Date /10Permit Expiration Date �IriS-�f I (or We)hereby apply for an 1Encroachment Permit to carry out the following work: �+ C-PT, Z l r'Oj, v rN,A tt,U �C�A ts o w. tom- tn- ATTENTION:Applicant/Contractor-you are responsible to �� m,1 replace all broken, damaged, and/or raised sidewalk,curb and PERMIT FEE........................... $ gutter from score mark to score mark adjacent to the parcel; �� remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $ The above named applicant hereby requests permission to Sewer Tap Deposit.................. $ P� TOTAL DEPOSIT ...... $ Py.Qtr S� S,,� Building Permit No. Improvement Plan No. Supplemental Conditions: :ALL. (20.q) g3%03f TO ItI'CIU 81 A GM, L 4JkG[—,r2 NO IFSS TllI,N'Zf, i mi)i'IS, Ia1 t I t),r IN, ? XC:c Ot 7x t IOtJ€2a I"r71f�1�'ifS«�"i/,tT(J€=t f(1RI( Show sketch above or refer to drawing submitted IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit, as well as all applicable city ordinances,resolutions, 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 not meet the above requirements. Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnify and hold the City 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 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 of this permit. IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937-8381. READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. Signed: ��_,PhonetlO -(2A9 33�R 1s'-Permittee(white) 2nd-Inspection(pink) 31d-File(yellow) 411h-Finance(white)