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CITY OF STOCKTON E97 9 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION OR ENCROACHMENT ON PUBLIC RIGHT OF-WAY <br /> Opplicant"s Name �­N, LIR k� ate '� APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner) ter ctor) ` Subject to the General Provisions and Special Conditions, <br /> Address I phone-V-6 M 3 39 and all work must conform to the project's approved Storm <br /> City it i�� State _Zip G�!�- Water Pollution Prevention Pian or the most current version <br /> Location of tion Proposed Work,etc a of the City of Stockton Storm Water Pollution Prevention <br /> p Maintenance Staff Guide,whichever is applicable <br /> c ! <br /> O vy_ner/Contractor Address AMIL 'Oei4ilo*o" <br /> Date <br /> Estimated Starting Date /j:7 Z4mpletion Data /6 O S� Permit Expiration Date t'�f <br /> I (or We)hereby apply for an Encroachment Permit to carry out the following work <br /> PT mtila S t4mli4tr� 6 AJ <br /> 11 4 w <br /> ATTENTION Applicant/Contractor-you are responsible to j 3zic7 d_e.%. <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 <br /> Sewer Tap Deposit $ <br /> TOTAL.DEPOSIT $ <br /> 1 � � A&-ek"4 Budding Permit No � <br /> 4� Improvement Plan No <br /> S,4w- �,lt.w Supplemental Conditions 10 <br /> 1 -3 <br /> }I EMIT NOT VALID WITHOUT A <br /> ,00 CONTROL NUMKFL <br /> (� <br /> ALL (2DD) 937-8368 TO REOLIEST A CON'T'ROL <br /> ` 4UMBER NO LESS THIW 24 HOURS, 13tIT NOT IN <br /> EXCESS OF 72 H05,F�RIQ� RT <br /> TS`AOf T <br /> :C3NTROl��� f�jj LL <br /> Show,ketch 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 <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 /> SEAD GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING <br /> Signed one D 3139 <br /> "Is'-Permittee(white) 2nd-Inspection(pink) 31d-File(yellow) 41h-Finance(while) <br />