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CITY OF STOCKTON 76565 <br /> �>) PdENCRO CHH DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAYCD <br /> MM Applicant's Name -�rr�L CdrJSu`I.TINC� �y Date��g�'�_"` APPROVED: BY THE PffBLIC-WORKS DIRECTOR <br /> (Owner/Contractor) _-LC "IG ILL[- Subject to the General Provisions and Special Conditions, <br /> Address '„]•';f-fib g gr"O f•Phone and all work must conform to the project's approved Storm <br /> pal��j L Water Pollution Prevention Plan or the most current version <br /> City Ltv *t+s State ZIP of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work,etc..C � t;70'J OF+ttiFTl '— Maintenance Staff/Gu'i`de,whichever is applicable. <br /> Lh I <br /> C nr P Fi{�l-ltiN � <br /> ' Date <br /> fi VO ?21, BY <br /> Owner/Contractor Address T -J &AKVi2Permit Expiration Date (1)SCompletion Date f?-JS <br /> Estimated Starting Date - -( C <br /> � <br /> i <br /> C'-9 6,LNd Ir �- <br /> ` <br /> I (or We)hereby apply for an Encroachment Permit to carry out the following work: eaw- ��� • y � <br /> �'WN fl9 AA V' WVA,/<2 'L't`d It! C <br /> W <br /> ATTENTION:Applicant/Contractor-you are responsible to <br /> � 3 � <br /> replace all broken,damaged,and/or raised sidewalk,curb and PERMIT FEE........................... $ V <br /> gutter from score mark to score mark adjacent to the parcel; <br /> remove USA markings upon completion of the permitted work. -AdlliTrnnal-EAetage-f=ee•pis$ to <br /> C C <br /> The above named apPlamal hereby requests permldaion to: �WetzFap depQ�jt:„• ............. 1 <br /> 61EIC /�5�1��1 -p R(+-- TOTAL DEPOSIT ...... $ �I (0 <br /> Wt-v,- W&MIdy'l S Building Permit No. <br /> l t ATQ 'f•wv 1 S <br /> 1 Improvement Plan No. <br /> Supplemental Conditions: <br /> K”'qS�UV�'1way v'au WW"'f <br /> p91G1 <br /> G�r)nII46' OL WWR <br /> CAIT (POD) q'V-i1y6 fO REOUF_-sT A ct fi Cs <br /> Uirf NOT If@ <br /> F Ct S Gr r I'(.)Ih'�pRIC)Ft TO START(T VIORIK <br /> _- <br /> �D`l�- <br /> n�f ?,t�q-139-1ZSZ <br /> Shaw sketch above a,refer to drawln9 auhmltted <br /> IMPORTANT: Applicant her agrees to comply with all provisions of this permit,as well as all applicable city ordinances, resoitem Which <br /> lutions, <br /> Standards <br /> oes not meet hSpecifications <br /> above ts requirements. Faiin lure to comply will be causto the eltforrevocai on ofpth s perctual cost for mit.Aand pple ant er agrees to indecement of mnity and hold <br /> the City harmless against any and all losses, <br /> tobeor a under es resulting <br /> this promiinju certificate of ersonsinsurance h of shal�ha submitted to the n or damage to property <br /> Risk <br /> occurring at the site of,or as a result of, performed <br /> Manager prior to issuance of this permit. <br /> 61ENCE WITHIN 72 HOURS OF THE ISSUANCE OF A ROL NUMBER,THE CONTROL NUMBER WILL <br /> BECOMEOINVAL 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 THIS PERMIT,P TEE SHALL CALL(209) P <br /> HE BEGINNING OF ANY RK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE <br /> SIDE <br /> 1. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> Signed: Phone:ao -a- -301r <br /> '7 t4 <br /> 1'I-Permittee(white) <br /> 2nd-Inspection (pink) 3`d-File-(yellow) 4m-Finance(white) <br />