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11— 6-07; 1 :42FM; ;2099836960 i9 2/ 5 <br /> ..r CITY OF STOCKTON `011101 71560 <br /> + PUBLIC WORKS DEPARTMENT <br /> / APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> C <br /> Applicant's Name A Date 7 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) Subject to the General Provisions and Special Conditions, <br /> t Address /9 `1t y fti�es i[, Dom, Phon�707 533.2 3L J <br /> and all work must conform to the project's approved Storm <br /> city, State t"/? Zip 95Y7 5. Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. 2y W, �' y« (�/� of the City of Stockton Storm Water Pollution Prevention <br /> L /+ P G _T__,__ Mainte Sf ff uide,wh' ever is applicable. <br /> t C s"4) C.o�^s+.�r eom of /�itrr�fa•, Date <br /> t Owner Contractor Address 20V!r f s frv.���+nrw�l�_�� BY <br /> r .t..•. r,. ojto j— /-- v <br /> Estimated Starting Date A&v_ 2u.7 Completion Date 4 to *10 C.,.// Permit Expiration Date g <br /> I (or We)hereby apply for an Encroachment Permit to carry out the following work: /Oft jr" y/e07i/�7 r*Ao L..t//f <br /> zyW /S S'O "d IoVW --IS-7 7 QIe /Wr fie rce <br /> c s r1c g t t rid .5. ../ rle r��+�+ �s,...fy iii�i�L.+..r�..l</ / ,o� Q tr�/�,���J t..,/�i <br /> e.e J,�•T� Cyt.u...q�..7� 41 /!. .r to// 1'�C �•, to&A4 Q/ CI.V Al G 1�"Z, <br /> ATTENTION:ApplicanVContractor-you are responsible to <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. Additional Footage Fee .......... $ <br /> The above named applicant hereby requests permission to: —fes' <br /> Sewer Tap Deposit.................. $ <br /> GO <br /> /2Ih/�1,ia/ �•�e f 4 r► �vacc,l;�TAL DEPOSIT ...... $ 3 <br /> Permit No. <br /> C7??_ <br /> Improvement Plan No, <br /> Supplemental Conditions: <br /> FcRMIT NOT VALID WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 937-8386 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TOST7AR/1T OF WORK. <br /> Show sketch above or refer to drawing submitted CO��-"-r��-OL"' SO O 2—Q I/ �/ E <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 <br /> Manager prior to issuance of this permit. <br /> IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A 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 CITY 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. r Phonel(2c1 frr$ Li/a <br /> ls'-Permittee (white) 2nd-Inspection (pink) 31d-File(yellow) 41h-Finance (white) <br />