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it Jan 19 OS 09 : 20a C - a of StocktonPll - Permit ( 2,rn ) 937 - 8901 P . 1 1, , n .,,.. n.^.rt - vl u . A7 ,. .EITY 13FITOCKTON g PUBLIC WORKS DEPARTMENT 69672 APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF--WAY Applicant's Name � it.- tG"' ( I a. r V FIt" Date It s Ito APPROVED: BY THE PUBLIC WORKS DIRECTOR (owner/Contractor) Address 'ii it Phone tt o ne 0 Subject to the General Provisions and Special Conditions, Addrh `; 1" n� -s + 41 ' `Y` `.7 7y and all work must conform to the project's approved Storm ' .r 1- e f f State �- A Zip _ Water Pollution Prevention Plan or the most current version City _ of the City of Stockton Storm Water Pollution Prevention Location of Proposed Work, etc. �?1 rtK I � t Iran ° Maintenance Staff Guide, whichever is applicable. , 13 0 Nor tri 1a .,n � r 5+; ' r7 CIF, Ic )' 1 u J. N C- t Zra �B _ _: ;%!r l[r ! Date Owner/Contractor Address 1 9 1 A0 I " y P f Estimated Starting Date ( t ' 1 I " `�I Completion Date 11 • 1 S ' 0 Permit Expiration Date I (or We) hereby apply for an Encroachment Permit to carry out the following work: r, . Y tit i ' MINNOW ATTENTION: Appllcant/Contractor - you are responsible to PZ replace all broken, damaged, and/or raised sidewalk, curb and ` PERMIT FEE . . . . . . . $ gutter from score mark to score mark adjacent to the parcel, . remove USA markings upon completion of the permitted work Additional Footage Fee . .. . . ... . , ' The above manned applicant hereby recoil Pemission b: -.. Trench Cut Fee. $ - - •�'. Sewer Tap Deposit . ... till TOTAL DEPOSIT . . . . . . IL Building Permit No. �- Improvement Plan No. FilltS , Inta Conditions: " Supplemental show sketch above or refer to dra l submitted Fossil IMPORTANT: Applicant hereby agrees to comply with all provisions of this penult, as well as all applicable City ordinances, resolutions, Standards andspecificationscurrently 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 rause 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 asa result of, work to be performed under this permit A-certifrcato of Insurance shall be submitted to the City Risk Manager prior to issuance of this permit. - °' ' - ` - PERMITTEE SHALL CALL (209)937A366 FOR A CONTROL NUMBER No,LESS THAN 24 HOURS, I3UT 1407 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)1)3T-3411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK ) i READ GENERAI . pROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. l Signed ,f ' , - - Phone: t ) 1 r / '� � -Y,