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CITY OF STOCKTON 6 7 7 1 8 <br /> C(DPPuBLIC WORKS DEPARTMENT <br /> ' APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicants Name COr-t a T Ear r� r�c/1nc+�c�ate f Z APPROVED BY THE PUBLIC WORKS DIRECTOR <br /> ' (Owner/Contractor) <br /> [� <br /> Subject to the General Provisions and Special Conditions and all <br /> Address B Fra W G S7 Phone1 Z3`f Q s/i work must conform to the projects approved Storm Water Pollution <br /> City ��� �C�n State�� Zip Prevention Plan or the City of Stockton Storm Water Pollution <br /> "114,* <br /> � S Z�,�1 Prevention Maintenance Staff Guide whichever is applicable <br /> ' •,� Location of Proposed Work etc r1t i<[151c Te.,,... a-f` p(l rla'� 1� <br /> C_o 't- C � CC rt` fi� s�afJ <br /> T-a 9-4 patw ec /z-0� <br /> Owner/Contractor Address By 4k44�� - <br /> Estimating Starting Date — / Completion Date 6Q-�_0"3 Permit Expiration Date <br /> ' I (or We) hereby apply for an Encroachment Permit to carry out the following work Lr/_ <br /> t 6r� n� f � I c� � <br /> a n c b r o V- <br /> 1 <br /> The above named applicant hereby requests permission to � <br /> �c.ch r•J p�rrn G 1.� i �� rr�t�L �,� �n11r0�( PERMIT FEE $ <br /> Additional Footage Fee $ <br /> C1 y q rLtG! L( r <br /> ' J Trench Fee $ <br /> Sewer Tap Deposit $ <br /> ' TOTAL DEPOSIT $ <br /> Budding Permit No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> 1 <br /> Shaw sketch above or rotor to drawing submitted <br /> IMPORTANT Applicant hereby agrees to comply with all provisions of this permit as well as all applicable City ordinances resolution$ <br /> Standards and Specifications currently in effect and to pay to the City its actual cost for removal and proper replacement of any stem 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 '�5 't f- Ccti'�rpt <br /> PERMITTEE SHALL CALL(2091937-8366 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 /> ECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER (FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> ic.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 THIS PERMIT 8 FORE SIGNING ��7y n /7����y♦ <br /> Ist Permittee(white) 2nd Insoeclion(oink{ 3rd FdP fvPllnwl d1h Finanrp rwhitpl <br />