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CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT C 0-v ? <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant'sName 641cr- Ryan xklic. Date 2 'ZZ OG APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) ) Subject to the General Provisions and Special Conditions,and all <br /> Address 6��} S i crtrA C� S-tfz 3 Phone 2Sl �� sr work must conform to the projects approved Storm Water Pollution <br /> City State C_ Zip 9456 S Prevention Plan or the City of Stockton Storm Water Pollution <br /> LocationPrevention Maintenance Staff Guide,whichever is applicable. <br /> of Proposed Work,etc. , c/1�i oN v � <br /> AGrShrna AVL 4 C�� �-lub QLVK� CSCE A> LI- <br /> Owner/Contractor Address By Date <br /> Estimating Starting Date Orl 2001 Completion Date Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: O►'tz _s"I I-_-or1,0 9 <br /> C+ CXpproxiNVeAte LCIC:G1<ion S�cxrh cov% Mc. a (At4�4c�d <br /> The above named applicant hereby requests permission to- <br /> I 1 ` c' PERMIT FEE............................$ .�S OQ <br /> J <br /> Cor�Q�t G GcG�)ro DG o r I )30✓r NI <br /> tt Additional Footage Fee............ $ <br /> ut3ri A A,CIA N Lc.r 4m Zh4LY Sccft'on <br /> 6P (:c,+,,�#-y C4 r✓ 6 /31.V b Trench Fee............................... $ <br /> VG-//• T� PIYfix.d <br /> Or-r9 Sewer Tap Deposit.................... $ <br /> LO C }SATOTAL DEPOSIT.........$ <br /> I z g 0 <br /> � , c- <br /> 1 <br /> PCrS�I,n Avc o . , c,&"w Building Permit No. <br /> Sr TC ^-CAP '�")5 LCCJ on Improvement Plan No. <br /> 1 n'i Supplemental Conditions: <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 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. <br /> PERMITTEE SHALL CALL(209)937-8366 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 /> 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: <br /> Phone�� <br /> �r_ao. tnoo 1-h fot 9nd-In-nartion(oink) 3rd-File(yellow) 4111-Finance(white) <br />