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CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT 7 0 ' <br /> APPIJCATION FOR:ENCROACHMENT ON PUS RIGHT-OF-WAY <br /> Applicant's Name t �^ 'r '�" ~9 ate. APPROVED BY,THE'PUBL(C cWORKS DIRECTOR <br /> (Owner/Contractor) <br /> Address ' Phoneh0dq"M� 'Subject to the General Provisions and Special Conditions; <br /> and all work must conform to the project's approved Storm. <br /> CityState Zip Water Pollution Prevention Planor the most current version <br /> of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work etc, Maintenance Staff Guide,whichever is applicable. . <br /> Owner/Contractor Address + tSig- By /r '/'r Ft �F�t Date ` d } <br /> Estimated Starting Date66.,*,195-04 Completion Date �► °��` Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out 1he following work: <br /> anV1.rM ffy joldi s6llY'6bl o 144: 26 <br /> ATTENTION: Applicant/Contractor—you are responsible to L� <br /> p g sidewalk, curb and PERMIT FEE........ $ r' . <br /> replace all broken, dame ed and/or'raised <br /> gutter from score mark to score mark adjacent to the parcel; <br /> remove USA markings upon completion of the permitted work AdditionalFootage Fee.......,,. $ <br /> Sewer Ta <br /> gamed applicant hereby requests:permisslon to <br /> he above '.. p Deposit.,.:... ...... $ •-�_ ,� ., .. <br /> >0 f i �t - ^ + TOTAL DEPOSIT $ <br /> Building Permit No <br /> Improvement Plari No. <br /> '� " d0f).5," �` �� Supplemental Conditions: q <br /> Alk <br /> 'Show sketch aboveor 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 mee't'the above requirements: Failure to comply wlll 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 NUMBER WILL <br /> BECOME INVALID AND THE PERMITTEE SHALL CALL FORA 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 WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE <br /> SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)q37-8381.'i - <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Signed: if+ � ! Phone: <br /> 151 Permittee(white) 2nd Inspection (pink) Mrd-File(yellow) 4!h-Finance (white) <br />