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CITY OF STOCKTON PUBLIC WORKS DEPARTMENT 68740 M9 M5 APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY IrItcant's Nance Date APPROVED BY THE PUBLIC WORKS DIRECTOR ner/Contractor)� K I 1 Address ont Subject to the General Provisions and Special Conditions, Chp and all work must conform to the project's approved Storm City State-__ r� Zip Water Pollution Prevention Plan or the most current version Location of Proposed Work,etc in 5td 0 JAjal LZ_ m Har of the City of Stockton Storm Water Pollution Prevention Maintenance Staff Guide,whi ver is applicable Own er/Con#ractor Address LYl y Date Estimated Starting Date Completion Date 41Permit Expiration Date_ —1—C,75I (or We)hereby apply for an EncroactimertcV Permit carry out the following I StA L Ic±I f 9- Lo S ATTENTION Applicant/Contractor—you are responsible to $ Z 36 0 replace all broken,damaged, and/or raised sidewalk,curb and PERMIT FEE gutter from score mark to score mark adjacent to the parcel, f remove USA markings upon completion of the permitted work Additional Footage Fee $ The above named applicant hereby requests permission to $ �G 3 72 Trench Celt Fee �C C 5 Sewer Tap Deposit $ TOTAL DEPOSIT $ Q 2Fe>• a�.l�r APs Fi U t_e S_ vauh,11e BeMdin Permit No Improvement Plan No Supplemental Conditions 09f �Iaf Show sketch above or refer to drawing submitted IMPORTANT Applicant hereby agrees to comply with all provisions of this permit,as well as all applicable City ordinances,resolutions, 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 not meet the above requirements Failure to comply will be cause for revocation of this permit Applicant agrees to indemnify and hold the City 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 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 of this permit PERMITTEE SHALL CALL(209)937.8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS,PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT. IF WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER. (FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937.8411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) 0 GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING Signerd yAa Phon 1—cam 1s'-Permittee (white) 2n°—inspection(pink) 3rd-File (vellow) 4th-FinanrP twhrtp)