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CITY OF STOCKTON - 69662 PUBLIC WORKS DEPARTMENT M&M57MAPPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY Applicant's Name a Jelate (Qr APPROVED: BY THE PUBLIC WORKS DIRECTOR (Owner/Con actor) b Address hone uV Subject to the General Provisions and Special Conditions, It. _ and all work must conform to the project's approved Storm City State Zip 5� Water Pollution Prevention Plan or the most current version Location f Proposed Work, of the City of Stockton Storm Water Pollution Prevention P Maintenance Staff Guide, whichever is applicable. S Owner/Contractor Adkds By Date Estimated Starting DateBZZ-5 Completion Date .2. Permit Expiration Date�� I (or We) hereby apply for an Encroachment Permit to carry out the following wor : Dry-si`tyfS r! - <9PJl &CO ZOC G2_ ATTENTION: Applicant/Contractor—you are responsible to replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ �� gutter from score mark to score mark adjacent to the parcel; remove USA markings upon completion of the permitted work. Additional Footage Fee .......... $ The above named applicant hereby requests permission to Sewer Tap Deposit.................. $ TOTAL DEPOSIT ...... $ . Z0 Building Permit No. Improvement Plan No. ,�A Supplemental Conditions: PERMIT NOT VAUD WITHOUT A CONTROL NUMBER. CALL (209) 937-&W TO REQUEST A CONTROL Show sketch above or refer to drawing submitted t&IMBER NO LESS THAN 24 HOURS, BUT NOT IN i i:GSSnc71 U DTn cTADT nc wnRK IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit, asw0lh> � plicable city ordinances, resolutions, Standards and Specifications currently in effect, and to pay to the City its actual cost for reA nd proper reptacemerr otar Tlt'emwhich does not meet the above requirements. Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnify and hold the City 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 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 of this permit. IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER. (FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937-8381. READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. Signed: Phone:f97 li)b 151-Permittee (white) 2nd-Inspection (pink) 3`d-File(yellow) 41h-Finance (white)