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I ' CITY OF STOCKTON 67883 PUBLIC WORKS DEPARTMENT T APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHQF-WAY 41plicant's Name d nate4'.IW-S APPROVED BY THE PUBLIC WORKS DIRECTOR (Owner) ctor {rA Subject to the General Provisions and Special Conditions,and all Address b 3 �+.�,1 �}( Phone work must conform to the project's approved Storm Water Pollution City �S#C5 State zip 15-11 Prevention Plan or the City of Stockton Storm Water Pollution Prevention Maintenance Staff Guide,whichever is applicable Location of Proposed Work,etc 314 7 SC Anf� Dc-4c t Jj/Contractor Address � 1�02 �', lt Z` _ _ 1By ( Date Estimating Starting Date 7`15 _L)S Complebon Date 7 18-�,! Permit Expiration Date I (or We) hereby apply for an Encroachment Permit to carry out the following work In C-u 11 l-A� r"�� x t , C c'r fl z I ft f1'1 PZ ` o t� D ,c. S-t. ,r� in Ctrs G aS �'eV - "_.t. L►J . The above named applicant hereby requests percussion to J3 44 PERMIT FEE $ ire' �1an A �+ Additional Footage Fee $ �- Trench Fee $ r/ Sewer Tap Deposit $ TOTAL DEPOSIT $ Budding Permit No ' Improvement Plan No Supplemental Conditions Show sketch above or refer to drawing submitted ' IMPORTANT Applicant hereby agrees to comply wrth all provisions of this permit,as well as all applicable City ordinances,resolutions, 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 not meet the above requirements Failure to comply will be cause for revocation of permit Applicant agrees to indemnify and hold the City harmless against any and all losses costs,or damages resulting from injury to persons,death of person or damage to property omumng 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 Manager prior to issuance of this permit PERMITTEE SHALL CALL(209)937-8368 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL *OME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER (FOR CAPITAL IMPROVEMENT PROJECTS OR ' DIVISION IMPROVEMENTS PERMITTEE SHALL CONTACT THE ASSIGNEE?CITY PROJECT ENGINEER AT(209)937-8411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK) I READ GENERAL PROVISIONS ON REVERSE SID IT BEFORE SIG ING ` Signed Phone ,[J6 7 1st-Permittee(white) d-Inspection(pink) 3rd-File(yellow) 4th-Finance(white)