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CITY OF STOCKTON <br /> PUBLIC �~ <br /> WORKS DEPARTMEN <br /> T .. <br /> APPLICATION FOR ENCROACHMENT ON PUBLICT-OF-W , S <br /> RIGH AY— cts <br /> LL, <br /> "74 Applicant's Name'.i)(.; { LL,irtz",M- _."*�-i Date ' ,(OwnerlContractor) APPROVED: BY THE PU61=1C VCTOI '! <br /> �.- <br /> Subject to the r Provision <br /> 1 General s and S ectal Conditions,an aiv <br /> Address t �� �L ;", + <br /> P <br /> �c_ �• .�t C`�-'�� Phon � � work must conform to 1t1e project's approved Storm WateC�i tfon <br /> City State i�,Zip �] Prevention Plan or the City of Stockton Storm Water Po <br /> 1 Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc. <br /> Owner/Contractor Address BA"'. ermit <br /> Date -'L <br /> Estimating Starting Date —7j�3�C Completion Date —3 k--< Expiration Date 4t 1,5--©� <br /> f (or We) hereby apply for an Encroachment Permit to carry out the following work:a;�±ni1 ito c� Ck - <br /> PC, LLS eLL c <br /> r <br /> l <br /> The above named applicant hereby requests permission,lo <br /> - <br /> PERMIT FEE .............................$ <br /> Additional Footage Fee............ $ <br /> Trench Fee ............................... ffi <br /> Sewer Tap Deposit.................... $ <br /> TOTAL DEPOSIT.........S I <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> C'i(�4nc�lrC..- <br /> sketch above or refer to drawing submitted; l <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit,as well as all applicable City ordinances, resolutions, 1 <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 /> harmiess against any and ail 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 /> ?RICK TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT.1F 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 /> SUBMVISION 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 THIS PERMIT BEFORE SIGNING. i <br /> Signed: ` Phone: � 'Q7�1 <br /> l a <br /> tet Permittee(white} 2 -Inspection(pink) 3rd-File(yellow) 4th-Finance(white) <br />