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CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENTnom.. 2 6 N01 196369 <br /> AFA4 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-�v12W O1.34W <br /> Applicant's Name LH' I'( HI LL. Date 01-01 C` I APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor)) c _ ���,,1 Subject to the General Provisions and Special Conditions,and all <br /> Address I JII,,S t�1'1�Yl'� Ci l �l'- ' f i I f JW Phone ��i C: Z,L lX x work must conform to the project's approved Storm Water Pollution <br /> city l-'OI.ICJ(� State C� Zip Prevention Plan or the City of Stockton Storm Water Pollution <br /> rPrevention Maintenance Staff Guide,whichever is applicable <br /> Location of Proposed Work,etc. tiJ2 zl1-J n R 4'd tri Hc',t �'`( `H cL <br /> T t 1- yy <br /> Owner/Contractor Address By Date <br /> Estimating Starting Datel�-T I -,'O!) 1 Completion Date -. Permit£zpiration Date <br /> l <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> LT..r , f til =-( .t^�,., :•.,_ ''tli��\ �;• . �. ,1''� 7 -� I_. _ �„ — I• <br /> f <br /> f <br /> t <br /> "A <br /> The ahove named applicant hereby requests permission to <br /> PERMIT FEE............................$ <br /> Additional Footage Fee ........_.. $ -=- <br /> Trench Fee.............................. $ <br /> Sewer Tap Deposit.................... $ ?= <br /> TOTAL DEPOSIT....._—$ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions,)� <br /> S7k1 IT>CC� h Sii <br /> e� Khv�- t , <br /> 1 <br /> Show sketch above or refer to drawing submitted t/'f11\1^ r ac` �M1^ )� <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit,as well as all applicable ICity y'ordinance,-,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. 0`70 <br /> I O 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 OFT IS PEMIT B773rd-File <br /> G. <br /> Signed: Phone: 7 s) - /t <br /> 1st-Permittee(white) .2nd-Inspection(pink) (yellow) 4th-Finance(white) <br />