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GIN OF STDCKTON <br /> EPART <br /> PUBLIC WORKS DEPARTMENT RECEIVED 69077 <br /> I 7 Q APPLICATION FOR ENCROACHMENT' ON PUBLIC RIGHT-OF-WAYMM5 DEg� <br /> Applicant's Name bane Md - '4y6 Date I1-'� - k APPROVED: BYTTHE PUBL(C RKS DIRECTOR <br />( (ownur/Contractor) Q0 <br /> Address t`tC. no �( `;a JI Subject to the Galdio$iUlecial Conditions, <br /> antl all work must conform to the projects approved Storm <br /> f Clly 4< �1 $G. .Mate Zip q!E1 ) 1 Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. -r)aA6s%J « �aY-V of the City of Stockton Storm Water Pollution Prevention <br /> Maintenance Staff Guide, whichever is applicable. <br /> 130 Nof - AAurt'ceY 5t✓za� ! (' ��—C7 <br /> Owner/ContractorAddress CI+J of 410Ltm 4 �ZJ ) P!+y he <br /> —c, s.IITr �c�Fai ec c <br /> Estimated Starting Date jr t9 =OLI Completion Date � t- Id O� Porrnit Expiration Date _ L"31 Oil <br /> I:(or We) hereby apply for an Encroachment Permit to carryout thefoflowing work;, <br /> Cr <br /> I ui t tri G[ <br /> C <br /> ATTENTION: Applicant/Contractor you are responsible to <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE . ; . :: . :.: . . . . .. -3e 106 <br /> gutter from score mark to score mark adjacent to the parcel;_ <br /> remove USA .markings-upon completion of the permitted work: r Additional Footage <br /> The above earned:applicantherebv request$ perselseionro:. <br /> Trench Cut Fee . . , . . .;. ., , . . , . . . . $ , <br /> 1 Sewer Tap Deposit . . . . : ;: ., . . . . . ...$ <br /> TOTAL DEPOSIT . . . . . . s 0 OC? <br /> Building Permit No. <br /> V8 I Improvement Pian No.Supplemental Cond:tions; <br /> PERMIT NOT VAUD' HOUT A <br /> C ROL NU 'R, <br /> CALL (209) 93743W TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> VQESS OF 72NUUAS PRIOR TO START OF <br /> Shaw sketch above or refer to Oavilro aubmlft d ONTROU . . <br /> IMPORTANT: 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 antl proper replacement of any tram which <br /> - does not meet the above requirements. Failure to. comply will be cause for revocation of this permit Applicantagreesto Indemnify and hold.- <br /> -the City harmless against any and all losses, costs$ or damages resulting from Injury to persons, death of;paraon or damage to property <br /> occurring at the she or, or as a result or, work to be performed under this parmlt, A certificate of Insurance shall <br /> be submitted to 'the City Risk <br /> Manager prior to issuance of this permit. <br /> PERMITTEE SHALL CALL (249)937�03e6 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS, BUT NOT IN EXCESS OF 72 HOURS, PRIOR, <br /> TO THE START OF WORK, AND PRIOR TO ANY REQUIRED INSPECTIONS, AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT, IF <br /> WORK DOES:NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER, THE CONTROL NUMBER WILL BECOME <br /> INVALID AND THE PERMITTEE SHALL CALL FOR ANEW CONTROL NUMBER. _(FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION <br /> IMPROVEMENTS, PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT (209)937-&411 FOR SPECIFIC <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK,) <br /> READ:GENERAL PROVISIONS ON THEREVERSEOF THIS PERMIT BEFORE SIGNING, <br /> ,Signed: _ Phone; <br /> 1v' •Permittee (white) 2nd -Inspection (pink) 3r4-File (yellow) 4id•Finance (white), <br />