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CITY OF STOCKTON 67769 <br /> PUBLIC WORKS DEPARTMENT <br /> MK"wi <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> 5 Nom/ <br /> Applicant's Named_ _ _ EwVlRoi, atex�Q3 APPROVED' BY THE PUBLIC WORKS DIRECTOR <br /> {Owner/Contractor) <br /> Address 3 Z(� /V. /L1�]�k�f L3L f�17 Phone 4 I y25- 7 Subject to the General Provisions and Special Conditions,and all <br /> work must conform to the project's approved Storm Water Pollution <br />' City '5,A68AI&VAM State G A zip rj S fl'3 I/ � Prevention Plan or the City of Stockton Storm Water Pollution <br /> Prevention Maintenance Staff Guide,whichever is applicable <br /> Location of Proposed Work,etc . L,.-,e.1'1- H��7M� <br /> ST aGk ov, LA , Q <br /> Owner/Contractor Address By Date <br /> Estimating Starting Date' �y 03 Completion Date C7rl -O; Permit Expiration Date _/0- G/-O <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work <br /> P M Gp-r 130R)AI&S FOR ,V o v' <br />' One k1h1h1"n tis e w o eP LGh.e r4e rpit ..re <br /> �.to d� /► T. ��` <br /> RETThe above named applicant hereby requests permission to <br /> RETi7- l Tb il�IA16 PERMIT FEE $ I3 ��7 Do <br /> Additional Footage Fee $ -'t9' <br /> Trench Fee $ -49- <br /> Sewer Tap Deposit $ -6;r <br /> TOTAL DEPOSIT $ 3 g f7V <br /> Building Permit No <br /> Improvement Plan No <br /> Supplemental Conditions <br /> All vSA /Wa.rklil shall All re~,-ed vomit <br /> Cd ny/efii�l il t^4+o"K <br /> Art)e.!P,4v C¢j '/tf <br /> o4oiAj CoX.F. aha 1l <br /> 94tea cpl ,�'ow� sc.w I'N.c ll f► SG pit wt Mr r� <br /> Show sketch above of refer to drawing submitted <br /> rIMPORTANT 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 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 /> 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 <br /> 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 <br /> 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, <br /> PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> RMIT IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> COME 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)937-8411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PERMIT BEFORE SIGNING <br /> Shc C <br /> ��� Signed �� Phone W6)..-.56 " <br /> 1st Permittee(whlte) 2nd Inspection(pink) 3rd Flie(yellow) 4th Finance(whlte) <br />