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JAN/02/2008/WK 03: 49 PM P. K I '00: <br /> N%.. CITY OF STOCKTON �5?�053, <br /> PUBLIC WORKS DEPARTMENT ._ _.. __ 7 1 4 3 8 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY 07 Z2w <br /> Applicant's Name 62-4-5 tis —Roves �-� ate ! i v APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner ontracto ��L3� Subject to the General Provisions and Special Conditions, <br /> Address �/S �i IL,'•c..SW Phone 70-Z- ?,3 2349 and all work must conform to the project's approved Storm <br /> City Sa o State GA Zip 1I5`1-7L Water Pollution Prevention Plan or the most current version <br /> of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. S;�c /2;-7 .><-� c Ag_ zaAb 14Maintenance Staff Guide, whichevy is applicable. <br /> wn Contractor Address 1_c?y S S �� Lr�n.ft+�c. SY __�!�'v—y/ ✓' ate Z��� <br /> Estimated Starting Datepe,_7,nl:—: Completion Date ermit Expiration Date �'3%��� <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> -7 GL <br /> <4,4r,_ <br /> ATTENTION: Appllcant/Contractor—you are responsible to A" <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ 773 <br /> gutter from score mark to score mark adjacent to the parcel; <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee .......... $ <br /> The above named appllcant hereby rccussts permiss,on to: <br /> // <br /> SeAr Tap Deposit.................. $ <br /> TOTAL DEPOSIT ...... $ <br /> Building Permit No. <br /> Improvement Plan No. <br /> I <br /> Supplemental Conditions <br /> PER�+A T NOT VAUD WITHOUT A <br /> CONTROL NUBER.. <br /> CALL (2C9) 937-&268 TO REQUEST A CON-1 ROL <br /> NUMSER NO NOT 1�1 <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> CAMTROLO <br /> Show sketef above or refer to drew,ng"bmltted <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 itern which <br /> does not meet the above requirements. Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnify and hold <br /> the City harmless against any and all losses, costs, or damages resulting from injury to persons, death of person or.damage to property <br /> 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 <br /> Manager prior to issuance of this permit. <br /> IF THE WORK DOES NOT COMMENCE 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 SPECIFIC <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE <br /> SIDE OF THIS PERMIT. PERMITTEE SHALL CALL(209)937-8381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Signed: Phone: <br /> 1s'.-Pe-61tee (white) 2"-Inspection (pink) 3111-File(yellow) 40'-Fir.ance (white) <br />