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�.' CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT ' <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicants Name —Date APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) `�i�' <�'°��°� tAt`v---r <br /> r Li.V��. ,, ��''�"- Phone t'�i-� ' `-���2�-�-�"i� Subject to the General Provisions and Special Conditions, <br /> Address <br /> I' and all work must conform to the project's approved Storm <br /> City State C-rt Zip `�{ _J')° Water Pollution Prevention Plan or the most current version <br /> Location of Pro posed Work, etc. _ of the City of Stockton Storm Water Pollution Prevention <br /> P ` _t try+ < -re- 'kt _ ( Maintenance Staff Guide,whichever is applicable. <br /> r <br /> Owner/Contractor Address F 1a i4 3 # `ttk L`r" By://', . ��� .�r�r�� a` Date �r J! �✓ <br /> E.. _. <br /> Estimated Starting Date r��x r ��>V" Completion Date �e:_r� .-� �!� Permit Expiration Date-.:)---/-� <br /> A( <br /> 0 } <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: e I ,�j F" i f <br /> — r�V,+ 4.,µF f a 'n`'Y - I.,.. G <br /> ATTENTION:Applicant/Contractor-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; c.t <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $ i 4e <br /> The above named applicant hereby requests permission to <br /> Sewer Tap Deposit.................. $ <br /> ~ Y .�_ � .•. 'r gi`-r 6 TOTAL DEPOSIT ...... $ <br /> Building Permit No. <br /> Improvement Plan No. <br /> -t <br /> J es. _� `� <br /> Supplemental Conditions: <br /> PERMIT 140TVAUE)W11 -AY, .­t <br /> CONTROL <br /> NUMBEr"C W,,), S La�8 X RDU S, so l 'NO-1 IK,! <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 <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 /> x <br /> Signed: d �' � zPhone: <br /> p <br /> 1s'-Permittee(white) 2nd-Inspection (pink) 3rd-File(vellow) 41h-FlnAnr A fwhifnN <br />