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PCITY OF STOCKTON 73572 <br /> UI3LIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAYoY <br /> Applicant's Name '14a►T-01-1 614trtR0►5tr$ateAPPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (C3wner{GonFrSubject to the General Provisions and Special Conditions, <br /> Address A4Ct-+0 rb44,Vi b�• Phone and all-work must conform to the project's approved Storm 1 <br /> City Irl- lbolft o utZ.t: State CA, Zip el EWA Water Pollution Prevention Plan or the most current version <br /> of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. �7-� t Pre P4�"4�1V,�. Maintenance Staff Guide,whichever is applicable. <br /> u► Sv10 IgArrses" 4. <br /> Date 7r! / I <br /> Owne Contract or Address ' Lvr R4,,—1 � �yehnast$CBY <br /> Estimated Starting Date 015-o1-t'O Completion Date- Permit Expiration Date S f <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work($ <br /> c 3 tr t'a,^ mtov �o At tA w-4 [oee&ed-A �feurc V .t vA <br /> 'x j-z E/l Fmw_ouk �0t4 . 'kW rJOWL 44Pi �f'LV�YI�I✓! 4tC�9' ' <br /> axi <br /> replace <br /> ATTENTION: <br /> broken,Applicant/Contractor <br /> Land/or raised sidewalk risible to �� � <br /> ' curb and PERMIT FEE.......:................... $ - , <br /> gutter from score mark to score mark adjacent to the!parcel; j G Z <br /> remove USA markings upon completion of the permitted work. /additional Foota/gJe FPP ......... $ l (f <br /> The above named applicant hereby requests permission to: /<- / Q r <br /> Sew ......... ..... $ <br /> TOTAL DEPOSIT ...... $ 49 <br /> u�Permiit No. Off- <br />' Irrmpeovement`Pian No. <br /> Supplemental Conditions: <br /> PERMf' NOT VAUD SHOUT A <br /> CONTROL NUMBER. <br /> :;ALL (2()9) 9374M TO REQUEST A CONTROL <br /> NUMBER NO LESS THM 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK, <br /> SOL ' <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 <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,or as a result of,work to be performed under this permit.Acertificate 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!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 SPECIFIC <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE. <br />!I SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209}937-8381. --_� <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Signed: Phone: <br /> 1s1 -Permittee (white) 21,13-Inspection (pink) 3r11-File (yellow) 41h -Finance(white) <br />