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10 / 29/ 2004 15 : 50 209- 579- 2225 MUDESTO ATC PAGE 02 <br /> CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT 68964 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicants Name _/f7CgSCOc /&r~ Date APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> ontractor <br /> Address 00Ae.01 #1 spa Phone Zn 9579 Zi zs f Subject to the General Provisions and Special Conditions , <br /> and all work must conform to the project's approved Storm <br /> City - /k op Lcs -ra, _ State CA Zlp TlU -T Water Pollution prevention Plan or the most current version <br /> Location of Proposed Work, etc. & S v' r , bdL or I nut ct of the City of Stockton Storm Water Pollution Prevention <br /> Malnten ce Sta Guide, whichever Is applicable. <br /> Z <br /> S7 vt� � y G< wtav <br /> Owner/Contractor Address / 7 [ ov t-+1 ✓� By 6(4 <br /> � / 7,Co / <br /> / <br /> at- <br /> Estimated Starting Date m Completion Date Permit Expiration Date- -^ <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: /" T ?Aa c C5 v 4:5 ll4Y�./1]Iwnfr <br /> A4 0. e/ 1-7bF f J; rnJ C. LL , <br /> ATTENTION : Applicant/Contractor — you are responsible to <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE . $ �7p <br /> gutter from score mark to Score mark adjacent to the parcel; <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee . . . . . . . . . $ "t� <br /> The Ybeye Wnwd epplkinl hweby rpusem prnnlma146 Ip' <br /> Trench Cut Fee. . . . . . . . . . . . . . . . . . . . . . $ <br /> Sewer Tap Deposit . "CT <br /> TOTAL DEPOSIT $ Z' • <br /> Building Permit No, <br /> Improvement Plan No, <br /> � Ny VALID MYMff A Supplemental Conditions: <br /> OIYTM NUMIL <br /> 937dfSB TO REQUEST A CONTROL <br /> �P _ oy L\/ <br /> NO <br /> ILESS THAN 24 HOURS, BUT NOT IN <br /> 01` 72 WOURS PRIOR TO START OF WORK <br /> CGN'fRO� <br /> ahs Vk* cn .bey er NfYr b dnwbw rubmeNd <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions Of this permit, as wall as all applicable City ordinances, resolutions, <br /> Standards and Speclflcatlons 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, of 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 /> PERMITTEE SHALL CALL (209)937$366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS, BUT NOT IN EXCESS OF 72 HOURS, PRIOR <br /> TO THE START OF WORK, AND PRIOR TO ANY REQUIRED INSPECTIONS, AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT, IF <br /> WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER, THE CONTROL NUMBER WILL BECOME <br /> INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER. (FOR CAPITAL. IMPROVEMENT PROJECTS OR SUBDIVISION <br /> IMPROVEMENTS, PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT (209)937-6411 FOR SPECIFIC <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK) <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING, <br /> Signed: Phone: <br /> 16, •Permlttee (white) 2"d -inspection (pink) 3rd-File (yellow) 41h-Finance (white) <br />