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3 <br /> r <br /> o CITY OF STOCKTON <br /> zk PUBLIC WORKS DEPARTMENT e~1"CTi: <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY / �y <br /> /l)D,q 214�c�D s f 3 <br /> )Applicant's Name IR�rDiJJt�7.L4 1`wK' Date_I /11 o 3 APP <br /> (Owner/Contractor) ROVED: BY THE PUBLIC WORKS DIRECTOR <br /> 5TE Subject to the General Provisions and Special Conditions,and all <br /> Address SJ�� �ftN"IrG a+-t6ZeY S-ri 10.5D Phone SS- work must conform to the project's approved Storm Water Pollution <br /> City Sr State « Zip /// Prevention Plan or the City of Stockton Storm Water Pollution <br /> Prevention Maintenance Staff Guide,whichever is applicable. <br /> � Location of Proposed Work,etc. 51P@N?d..bC /2 rFDI.�� Ac-ND � <br /> 11� QF- <br /> Owner/Contractor Address -STbGf,CZ� i + <br /> It a K 2 v & U i/ fBy /r Da _ <br /> Estimating Starting ate I� f5 AP 3 Completlon Date 1.�rTE��s/off Permit Expiration Date S <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: 3 IN 1/a5TI Gfk-ryE <br /> y1 r`. �syty 1�Ee S ��`I t 1 t N TIS G1 <br /> —1y <br /> 'b <br /> The above named appticam hereby requests permission to- �C <br /> PERMIT FEE............................$ <br /> sE� ^ Additional Footage Fee..........,• $ <br /> t`��C�ED �f G <br /> ixiz Trench Fee............................... $ v <br /> Sewer Tap Deposit.................... $ <br /> TOTAL DEPOSIT.........$' <br /> Building Permit No, <br /> Q4W.N,e. <br /> S'upplementai C.aniYit'ions: <br /> Show sketch above or rater 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 indemnity and hold the Cjty <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 shalt be submitted to the City Risk Manager prior to issuance <br /> PERMITTEE SHALL C 209)937-8366 F A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE STAR OF WORK,AN IOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PER IF WORK DO N N 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 IMPROV OR <br /> SUBDIVISION IMPROVEMENTS,'PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER 09)937-6411 FO <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING F ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE O T IS PER ITB F RE SIGNING. <br /> Signed: Phone: �I Vr �~ •��� <br /> tst-Pennirlee(while) 2 -Inspection(pink) 3rd-File(yellow) 4th-Finance(while) <br /> 2068 LE6 602 <br />