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CITY OF STOCKTON 67729 <br /> PUBLIC WORKS DEPARTMENT <br /> �` APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's a C� I tr� I C Date 2A6.10 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/ ont actor) <br /> AZAS NG <br /> ��_ ��U ` � Subject to the General Provisions and Special Conditions,and all <br /> Address,Z 3-� AZAS NGCT �+*S,=t -tp• Phonecgi&.) work must conform to the project's approved Storm Water Pollution <br /> City QV -0 Q \144- —State , Zip Q S97V Prevention Plan or the City of Stockton Storm Water Pollution <br /> Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc. <br /> -!:— NPlry.i Or JV <br /> d� �� �� �) <br /> �t tt.J 1`f�sN'i r- iirl NAV- <br /> Owner/ <br /> ay"Owner/Contractor Address `� rt'�E B Date 5 <br /> -' <br /> Estimating Starting Date Z f 2�+"/�� Completion Date '' -- 2 F'�' Permit Expiration Date r <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: I p'-l�j <br /> El)c rs 177 ti 6 cel'.eu"D tc,l r'401"9 : /"c UJ49-4-- S;NCi rJI'�' -t <br /> L'tVL-L-z:;� G`;rpt A L-,i is-' C &.Trs.oiz.c <br /> i&" Pi 9-1k 6-'7r--� <br /> The above named applicant hereby requests permission to- 3 i <br /> _ 0 <br /> ..:.. PERMIT FEE............................$ <br /> T u <br /> Additional Footage Fee............ $ <br /> Trench Fee ............................... $ <br /> Sewer Tap Deposit.................... $ <br /> TOTAL DEPOSIT.........$ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> )1 /41/.*a&- <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 does <br /> not meet the above requirements.Failure to comply will be.cause for revocation of permit.Applicant agrees to indemnify and hold the City <br /> 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 <br /> 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 <br /> of this permit. <br /> PERMITTEE SHALL CALL(209)937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT.IF WORK DOES NOT BEGIN 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 <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF TH PERMIT BEFORI<SI ING. <br /> Signed: Phone: (qd4,0 ,e`&3 �� ) <br /> 1st-Permittee(white) 2nd-Inspection(pink) 3rd-File(yellow) 4th-Finance(white)01 701 4f`!Yew <br />