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11/12/2001 15:00 20946717"9 AGE STOCKTON PAGE 02 <br /> • r mea <br /> S CITY OF STj i-7DEPART <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicanrs Name A 1 ^•` t "°ij'at'vrne�s. APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (OwnerlContractor) Subject to the General Provisions and Special Conditions,end all <br /> Address Q2"7 G�. ..,., \D,� Phone 4�T1 ' r�� work must conform to the Project's approved StOmn Water PaNlhon <br /> Prevention Plan or the City of Stockton Storm Water Pollution <br /> City—6A,O1� State I!A zip—%5115 Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc. "fin W. <br /> /� / 7 <br /> Owner!Contractor Address By ?A' are` ' <br /> Fatmating Starting Date N ov-- —Completion Data ,IUO1T'�y' Permit Expiration Data <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work. sadQM- t�AQL lye <br /> 11_ 1 I <br /> r `k'ti <br /> rt 'Elie >W • ,^� f ^ R l V.. �d / JL7> r1 _ �L �P <br /> I 7 <br /> nr above named a pseetH hereby redeem PQe i$X an to , 1 <br /> PERMIT FEE............................$ <br /> Additional Footage Fee............ $ -� <br /> TrenchFee............................... $ <br /> Sewer Tap Deposit....................$ <br /> TOTAL DEPOSIT.......,.$ ke <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Show sketch above or m1w to dm h,a iftd <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit,as well wall applicable City ordinances,rasolutions, <br /> Standards and Specifications currently in effect and to pay to the City its actual cost for removal and proper replacement of any Itom which does <br /> not meet the above requirements.Failure to comply will be cause for revocation of permit.Applicant agrees to indemnify and hold the City <br /> harrdess against any and all losses,casts,or damages resulting from injury to persona,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 cedmcate of insurance shall be submitted to the City Risk Manager prior to issuance <br /> of this perrrdt. <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)9378411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF il�PER 17 B RE SIGNING. <br /> Signed; 1\ J Ph.: 10 <br /> isl•Permiree(white) 2nd-Inspeollon(pink) 3rd-Rle(yellow) dth-FlnanCS(white) <br /> r A.-I. 1 <br />