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CKTON <br /> S CITY OF STDEPART <br /> �-' PUBLIC WORKS DEPARTMENT vow 69157 <br /> , <br /> J( APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant st� m �Al /Y'I t�f�l �1� �?f�,yq(.s'.�hba4e APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner sairec Subject to the General Provisions and Special Conditions, <br /> Address t 'T_�t= �'> Phone tL and all work must conform to the project's approved Storm <br /> ✓tht Zip Y'S2/ Water Pollution Prevention Plan or the most current version <br /> G7° "� i �` C- ' of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc.�r aLzh f J� — Maintenance Staff Guide,which er is applicable. <br /> iAt& bice t-4 <br /> 7AoDK'� d / <br /> ­7E1MAV?W, rf✓f �Z By i Date / Z-6Q <br /> 57 <br /> wn `_/Contractor Addres r <br /> Estimated Starting Date %�a4 Completion Date -3 li Permit Expiration Date r�r f7 <br /> I (or We)hereby apply for an Encroachment Permit to carry out the following work: <br /> fig QS dir-serf .e <br /> � <br /> ))y./L� _ t y1�;JGT- <br /> 7Tu D64 Cul s=ep 1_1✓/D-S <br /> ATTENTION:Applicant/Contractor-you are responsible to Css <br /> replace all broken,damaged, and/or raised sidewalk, curb and PERMIT FEE ...................... $ <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 ......... $ <br /> The above rume0 appliraM hereby requests permission to: Trench (^..Ut Fee. <br /> Sewer Tap Deposit .................$ <br /> j� TOTAL DEPOSIT ...... $ 2 <br /> r Building Permit No. <br /> f Improvement Plan No. <br /> Supplemental Conditions: <br /> {HERMIT NOT VAUD WaHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 937-8386 TO REQUEST A CONTROL <br /> NUMBER No LESS EXCESS OF 72 OURS PRIOR T 24 HOURS, <br /> START OF WORK, <br /> Show sketch above or refer to drawbm submitted �i <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. A certificate of insurance shall be submitted to the City Risk <br /> Manager prior to issuance of this permit. <br /> PERMITTEE SHALL CALL(209)937-8366 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)937.8411 FOR SPECIFIC <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. A <br /> Signed`-'C.✓� Phone: ' �i'7•-/dd�a <br /> 1"-Permittee (white) 2nd-Inspection (pink) 31d-File (yellow) 41h-Finance(white) <br />