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10/20/2005 0941 2095224297 GEOLOGICAL TECHNTCS PAGE 02/02 <br /> '•y Of StocktanPW-Permit (2[ 937-8$p1 <br /> %meP. I <br /> CITY OF STOCKTON <br /> 0 ' 5 <br /> or Y. <br /> PUBLIC WORKS DEPARTMENT 69676 <br /> ld� r�,,PPLICATION OR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> aDrf /exhnr� <br /> licanrs Name Ra r,l 1;. y 0. Dote APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> /Contractor) <br /> Address �01p bl. {r.,tet {�lr,s phone Y ' S l� Subject to the General Provisions and Special Conditions, <br /> City State 2tp q 5 x�1 and all work must conform to the project's approved Storm <br /> Water Pollution Prevention Pian or the most current version <br /> Location of Proposed Work,etc. S i :w r• 1 1c;, rt of the'Clty of Stockton Storm Water Pollution Prevention <br /> Maintenance Staff Quide,whichever is apptioable. <br /> V�.�� �.�.(^TC {• .fir '�\i r f .�•t �\.. •' ,•7• " - <br /> Own etre Address ILL o '� . �.a<� i r ,� E. <br /> Estimated Starting Date i)g compleWn Date_ �` i�t Or' Permit Expiration Date l0 01 <br /> I for We)hereby apply for an Encroachment Permit to can out the following work: b a•• 1\ C P T. <br /> ATTENTION:ApplicanKontrestar--you are responsible to �7�7 v� <br /> replace all broken.damaged,and/or raised sidewalk,curb and . PERMIT FEE...................... $ ,3G tom' <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 /> flip ahavo named applicant uereby mgoeets permission to: : <br /> Sewer Tap Deposit.............,.... $ <br /> TOTAL DEPOSIT $ �Building Permit Permit No. <br /> -improvement Plan No. <br /> ! Supplemental Conditions: <br /> Sh.ek"above ar War to ftwi wbir tted <br /> �, rarer arr�ra. <br /> IMPORTANT; Applicant-hereby agrees to comply with aff provisions of this permit,as well as all applicable city ordinances,resolullons, <br /> standards and Specifications currently in effect,and topay to the City Its sMal cost for removal and proper replacement of any Item which <br /> does not meet the above requiramOnIA Failure to comply writ 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 lnjuryto ppeersons,death of person or daniags to property <br /> occurring at the alts of,or as a result of,work to be mts <br /> perfod under this permit A cwRa'ate of insurance shall be submitted to the City Risk <br /> Manager prior to issuanoe of this permit. , <br /> W THE WORK DOES NOT COMMENCE'WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> BECOME tNVALM AND TH1=PFA WTTEE SHALL CALL FOR A.N9W COMMIL NUMBM(FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTBy IPERUMME SHALLCONTACT THE AsmoHm crrY PRoaEcT ENGINEER AT(2cm tw-emi FOR'SP'ECIRc <br /> INSRUC I IONS PRIOR TO TKE BEGINNING OF ANY WORK.)PFISOR TO ANY ReQUiRED INSPECTION%As IDENTIFIED ON THE REVOSE <br /> SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(M)ov8 pm.' <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING.. <br /> Signed: •; G Phone, <br /> • nrrt cu r.,,nn,.n Oro-FinnncA fwhitP,l AL <br />