Laserfiche WebLink
Iwo <br /> CITY OF STOCKTON 180 -4 <br /> DEPART <br /> PUBLIC WORKS DEPARTMENT <br /> // <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> M05 <br /> Applicant's Name?I 8`L�) �/VLF-D Date 2-1 S 8 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) p ,, / tib Subject to the General Provisions and Special Conditions, <br /> Addrepss/__'017 S .3 Jc-v Phone (Z__ and all work must conform to the project's approved Storm <br /> City )-f 9 t� V4 State ('rzip Water Pollution Prevention Plan or the most current version <br /> I/,, of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. ''51 DE WA I L- A4,e i4 Maintene a Staff Guide, whichever is applicable. <br /> M lw AV- , t-- s� r <br /> Owner/Contractor Address // By / /�r.,/�G'Date <br /> Estimated Starting Date��6 Completion Date T—JL5 — Permit Expiration Date <br /> 1 (or We) here y apply)for <br /> an Encroachment Permit tocarryout the following work: <br /> L A S fZ( �.A? t�I \ V.,}4-�1 S 1 �C 4��. <br /> UF A/k-iPi AV P �J <br /> ATTENTION:Applicant/Contractor-you are responsible to3,?, <br /> q sc <br /> replace all broken, damaged, and/or raised sidewalk,curb and PERMIT FEE........................... $ J ! _ <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 named applicant hereby requests permission to <br /> Sewer Tap Deposit.................. $ <br /> (_ej,� 77 0 <br /> TOTAL DEPOSIT ...... $ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERW NOT UW WITHOUT A <br /> CONTROL WOOL <br /> CALL {209) 9378986 TO REQUEST A CONTRDL <br /> NUMBER NO LESS IHM 24 HOURS, WT NOT IN <br /> EXCESS OF 72 HOURS pR*R TO START OF WDRK. <br /> Shu.sketch above or rete,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 indemnity 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 /> 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(2D9)937-8411 FOR SPECIFIC <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE <br /> 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:VMAMLG. p Phone: '�67100/0 <br /> 1e'-Permittee (white) 2d -Inspection(pink) 3r11-File (yellow) 41h-Finance (white) <br />