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CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT 6 6 Yi 0 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> pocant'sN a WeSe�n Gam.-�^i�ice�l Date 41'18''.1001 APPROVED. BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/ ra } <br /> r._, Subject to the General Provisions and Special Conditions,and all <br /> Address [6 � / N7C�- af�` Phone 0aA'_" work must conform to the project's approved Storm Water Pollution <br /> City State C4 Zip 4s7 74' Prevention Plan or the City of Stockton Storm Water Pollution <br /> Prevention Maintenance Staff Guide whichever is applicable <br /> Location of Proposed Work,etc /Lo�t�i Si'� l�e4c/ 1S�f <br /> Owner/Contractor Address 19-19; B Date u <br /> Estimating Starting Date t / .26 xcw Complebon Date A //27 BAC Expiration Date ' <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work e� �►r (i�� 1c,1 aftwCPT �ir�eila <br /> / a /7 07` /SO �� t�.�wc.17 <br /> a e� <br /> /2 <br /> iAi <br /> The above named applicant hereby requests permission to <br /> PERMIT FEE $ <br /> Additional Footage Fee $ <br /> Trench Fee $ <br /> Sewer Tap Deposit $ ! <br /> TOTAL DEPOSIT $ i <br /> ex ocku <br /> Building Permit No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> z <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 a <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 PERMIT BEFORE SIGNING <br /> Signed Phone �s�1_roto -'r-300 <br /> 1st-Permittee(white) 2nd-Inspection(pink) 3rd-File(yellow) 4th Finance(white) <br />