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CITY OF STOCKTON 76472 <br /> r� DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> ,�j� _ Clj <br /> Applicant's Name )�(�yf�f�l6C(� C;taCry)utl%t:�✓� ate APPROVED: BY THE PUBL-tC-WCrRKS DIRECTOR <br /> (Owner/Con.ractor) l Subject to the General Provisions and Special Conditions, <br /> Address�93�" �Ie ACL .+ P-d—Ld Phone 9.0t^-410 /"' I�� and all work must conform to the project's approved Storm <br /> City sT°L�- "� . C,f,�} Zip 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. \ e Maintenance Staff Guide, whichever is applicable. <br /> "t W,esf , c J FISye,-4rf . r <br /> Owner/Contractor Address By `��10 pkz, Date J—13-is <br /> Estimated Starting Date 'MRl E ,"ZLt'i Completion Date J uA-L ;Z(1 13 Permit Expiration Date "1� <br /> (or We) hereby apply for an Encroachment Permit to carry out the following work_ )"r'S t- <br /> o V11 <br /> -ct1111av1 r ��� � bv� CSE )ate O ��; t4lo, � 7, <br /> -,r /Vk / <br /> ATTENTION:Applicant/Contractor-you are responsible to <br /> replace all broken, damaged, and/or raised sidewalk,curb and PERMIT FEE........................... $ Z; C)0 <br /> gutter from score mark to score mark adjacent to the parcel; p <br /> remove USA markings upon completion of the permitted work. 4 e` W $ '39 <br /> The above named applicant hereby requests permission to: O <br /> Seltzer Tan Deo osit.........q.'... $ (} <br /> TOTAL DEPOSIT ...... $ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> G� <br /> �A <br /> .,,.- ._T Q RCA 11.�.�� U V�,..�„ b <br /> E'I i. -.Zm ro L"-!"s 7E"1 '4 24 i �.;,. , L'JT [`:-1T "J <br /> €:X2-.8S int 72 F;OL"r' F-3 n M STAM Cr VI=L <br /> JQ <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 <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 RUZIBER 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 WORT(.)PRIOR TO ANY REOUIRED 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 /> SiPhone: 2- `6 <br /> ned: <br /> Qts� 11,U04N P s <br /> 15-Permittee(white) 211-inspection(pink) 31-Fila.(vpllow) 411-Finnnra(white) <br />