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S CITY OF STOCKTONDEPART 6 6 4 6 2 <br /> PUBLIC WORKS DEPARTME T MAY Q 4 2001 / <br /> APPLICATION FOR ENCROACHMENT ON PUBIGHT-OF-WAY 9 2�Q(� <br /> �(i�yt^th`f q V aTko w�`, ` v` <br /> Applicants Name 1. O.irAbil0,EV4U GEN ate � I X2-7 �Q� APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> 2-1ri ���k �nS S� C C Subject to the General Provisions and Special Conditions,and all <br /> Address � � Phonel�7" `�J-�� work must conform to the project's approved Storrs Water Pollution <br /> city S oyNo"A State CA zpq 5't-1 6 Prevention Plan or the City of Stockton Stomt Water Pollution <br /> 24011% cmSt Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc. �'e-2�Ov.? S1't'�'+�t <br /> (^ S�loek rah <br /> Owner/Contractor Address See oi-oV t', _ Iml Date <br /> Estimating Starting Date 70hQ S .10o , Completion Date Permit Expiration Date <br /> I (or Wgj ereby apply for an Encroachment Permit to carry out the followin work: TY1S Vr <br /> I ���iv.'t- �YI`�C-���ek-'\ave (+�s `� a�e�c aJcaw +�lv�1 • <br /> 5a orma <br /> The abwe named eppkeant nereey mquema;permission to- <br /> PERMIT FEE............................$ \ O <br /> Additional Footage Fee............$ <br /> TrenchFee............................... $ <br /> S��` Q (�C•' `'�. Sewer Tap Deposit....................$ Q <br /> TOTAL DEPOSIT.........$ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Show sketch at ow or refer to drawing submined <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 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. <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 BEF R(E��SI NTNG. 11�� T <br /> Signed:. �� •� �1� Phone:-70 -700 <br /> tst-Permittee(white) 2nd-Inspection(pink) 3rd-Rte(yellow) 4th-Finance(white) <br />