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Apr 20 01 08: 25a Ci --4 of StocktonPlr" •Perpn i t (20-1937-8901 P. 1
<br /> 54 . 1
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<br /> „ f NKTONi F:r,f s-�
<br /> Pul WwAtIS I PARTM�W
<br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY 5ROO2S
<br /> Applicant's NameG ' ;r-•I���. 'r � - Date z2 �� APPROVED: BY THE PUBLIC WORKS DIRECTOR
<br /> (Owner/Contractor) Sub ect to the General Provisions and S -
<br /> ' j pedal Conditions,and aA
<br /> Address 6.T 4 t c r r a �� }r f Phone UL work must conform to the project's approved Storm Water Pollution
<br /> City state�'- c < Prevention Plan or the City of Stockton Storm Water Pollution
<br /> r !.� j 4•, � . ��•r
<br /> ;.. zip 9.4 ` Prevention Maintenance Staff Guide,whichever is applicable.
<br /> Location of Proposed Work,etc. 'r.re r �,. }r,
<br /> v �.(.�^ is LV;. �•. .e ,t.*
<br /> Cc<-�•.•o Ar � ("mac.. :r << •,_`
<br /> Owner/Contractor Address �� Date -c�I
<br /> Estimating Starting Date F1 ,,3 f «'( Completion Date /t l 't emit Expiration Date i'CJ
<br /> r—
<br /> I (or
<br /> We)hereby apply for an Encroachment Permit to carry out the following work:
<br /> -r,.<G;,�a._._,:Eev Jr:r -!.. ...-,(t. .-v-e.,:.;r_. ";-t4i-.:-• 'ai' �yp,.t�us..�.ri-.caa ie.'TM� ic.�.lw*+!°l <�.,s,.--.,s>-. .t��-Ra.�� ._
<br /> The above named applicant hereby requests parmissiort to
<br /> PERMIT FEE...............:..:..:.....:$ OO
<br /> Additional Footage Fee
<br /> ir -71
<br /> Trench Fee...............................$
<br /> P , f 1 r r....<I Sewer Tap Deposit....................$
<br /> r I S I moi,k' d Q
<br /> L_r.,.f_: ,: r , �•� �/ t . TOTAL DEPOSIT.........$
<br /> ze
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<br /> Building Permit No.
<br /> i. �' ',-t: i F ;j� L;;C� < • improvement Plan No.
<br /> Supplemental Conditions:
<br /> - -i _- � __ -S _. - .- i... �'s�l�:'�'��"v1al�L•`:.-iu•�ii�.�: •-LL4''L-:-,��r t�"�i.I4�4'•.-+�_. - ..
<br /> �. ��. �a�..��..��.�.._.fit�r t.►�e� 'I,n �o lit ha,lr< .
<br /> Show sketch above or refer 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 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.
<br /> 'PERMITTEE SHALL CALL(209)937-8366 FORA CONTROL NUMBER NO LESS THAN 24 H0URS,.BUT NOT IN EXCESS OF 72-HOURS,
<br /> PRIOR TOTHE START OF WORK,AND PRIOR TQANY 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 /> 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
<br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)
<br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS P RMIT EFORE SIGNI
<br /> Signed: Phone �.Z' ' '..►r I f '
<br /> 1st-Permittee(whRe) 2nd-Inspection(pink) 3rd-Elle(yellow) 4fh•Rnance(white)
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