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Jan 14 05 01 : 29p C ' y of StocktonPW Permit t2 " '11937 - 8901 pill
<br /> Verrill
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<br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT OF WAY9go-IF
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<br /> e r I ua s ( : i` I � ""4'O`dEfl: PY THIF P1 PRE LIC WORKS DIRECTOR
<br /> Applicant's Name - IrJ r '
<br /> (Ownerlcontractor) r 4 i Subject to the General Provisions and Special Conditions '
<br /> Address � � �1 ' Phone 4 f = j" { and all work must conform to the project's approved Storm .
<br /> City ' ":r' , rr -� e� / I IF State - A Zip 1 - . Water PollutionPrevention Plan orthe inostcur rentveision
<br /> of the City of. Stockton Storm Water Pollution Prevention ai ,
<br /> Location of Proposed Work, etc. +h ' Maintenance Staff Guide, whichever is applicable
<br /> Fee
<br /> rill
<br /> 7. 3
<br /> Owner/ContractorAddress � ItI,. `� 51 - r �c1r �� 1 , �{ i t.� 4L9 By y{, �!.�+! , ; . ate ' (
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<br /> Estimated Starting Date � I IeL",v IF Completion Date It - I n " y I Pe OFExpiraUon Date "1Z " 3'i fxy '+
<br /> - I (or We) hereby apply for an Encroachment Permit to carry out thefollowingwork: F _ IF
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<br /> Seem ` i t 11 � . 1 f Y I �i IVT "1' frr, t
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<br /> A $10IV It, I
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<br /> ATTENTION: ApplicanUConVactor — yogareresponsihieto rill,IF" d3 �
<br /> replace all broken, damaged, and/or raised sidewalk, curb and ' PERMIT FEE $
<br /> gutter from score mark to score mark adjacent to the parcel; 4
<br /> ' remove USA markings upon completion of the permitted work Additional Footage Fee $
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<br /> Me above na, JPOIFFIF : : ..:. .. f F JIF
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<br /> IF ` " '" Sewer Tap Deposit a Ve
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<br /> fir f V. I a IF - 'k� TOTAL DEPOSIT ire'$
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<br /> I G i n pj'L 'IF or,Ik_t t y I Ill r
<br /> j ' � ✓ lZFBwlding Permit No I:OF fopr
<br /> �j Impravefnent Plan No T V:It '
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<br /> . Supplemental ConditiIll . IF
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<br /> .- - .J ,., to i t l>ir�, ey*eZr �i $1i M ii R t .. w- .I'.r(r IFy.zF4
<br /> IF
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<br /> IF Bhow eketCh shove or Te to dra&*W uFbmatod r ' � ' r'# I' I ; ri _: l t f +
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<br /> IF
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<br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit, sswell asap applfwble city ordinances, resolutions;emblem % l
<br /> Standards andpeel
<br /> curtently in effect, and to pay to the City its,actuaf cost for removal and proper replacement of any Item y filch I.
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<br /> does not meet the above requirements, Failure to comply Will be_muse for revocation:of this permlL AppllFantagrees fo-, fodemnlfyandhold
<br /> the City harmless against any and all losses costs or damages resultingfrom Injury to parsons death of person or.,damage to pro party - f
<br /> occurring at the site of, or as. a result of work to be performed under this peult A certificate of In�s!Rufance shall ba srtbItIl mitted to the Clry1 IF Rlsk
<br /> Manager prior to issuance of this permit ? }t, k r t,6h §�(gy+}" ' ,E r~ *-�' "' Yt44
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<br /> PERMITTEE SHALL CALL (209)937$366 FOR A CONTROL NUMBER NO, LESS.THAN X24 HOURS, BUT NOT EXCESS OF 72 HOURS PRIOR
<br /> TO THE START OF WORK PRIOR TO ANY REQUIRED INSPECTIONS, AS' IDENTIFIED ON THE REVERSE SIDE OF.T.NIS PERMIT :
<br /> WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL.NUMBERJIFIE CONTROL.NUMBER WILL BEGONE
<br /> INVALID AND THEPERMITTEESHALL CALL FOR ANEW CONTROL NUMBER (FOR CAPITAL.IMPROVEMENT PROJECTS OR SU6DNISION ¢t
<br /> IMPROVEMENTS, PERMITTEE SHALL CONTACT THE ASSIGNED CITYiIVV PgOJE,9T ENGINEER AT(209143T-6411 FOR SPECIFIC I� ' „ . }
<br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) { }y f's¢)s t` ' ; f a - *Hij�u + I _ n r k' i}� +�++`I r�+itIF
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<br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNINGFFL' Irt
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<br /> Signedr ,r. Phone f ) f 5
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