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SMCITY OF STOCKTONTt <br /> rV <br /> APPLIPUBLIC WORKS DEPARTMENTCATION FOR ENCROACHMENT ON PUBLIC RIG HT-OF-IrIA �, �A <br /> b <br /> Applicant's Name vg ,UA kite APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> Subject to the General Provisions and Special Conditions, and all <br /> Address `=i > 7 Phon work must conform to the project's approved Storm Water Pollution <br /> City 1'fi^,(. t'7rt Stated Zip Prevention Plan or the City of Stockton Storm Water Pollution <br /> � - Prevention Maintenance Staff Guide, whichever is applicable. <br /> Location of Proposed Work, etc. 1 S /U 4T rvgif yti 'sir''.' <br /> C � A <br /> Owned Contractor Address S"tin✓ E: 4 uda)V� By :/ � ' -'��f �� - Date � � - tt', L f <br /> Estimating Starting Date 13L1 Y� ItW 3, Completion Date09 1 Cc P% afire a Permit Expiration Date <br /> I (or We) hereby apply for an /'L7 Encroachment Permit to carry out the following work: y un ? cn I L,ar+✓x � <br /> C� t`1 9irG✓ ig4 , t k' i^ � l �.�-(iV7'�"Ct?'2i -Ac' e0if2ocf� CL �t1 R- 63rGvd 4octl{,'�ieS <br /> So ivsc n95 LA AFS 11? <br /> The above named applicant hereby requests permission to <br /> y <br /> PERMIT FEE ...:.::.-'.....:.:::........ $ 1 �- .. <br /> Additional Footage Fee ............ $ <br /> n <br /> Trench Fee ............... ........... ..... $ <br /> Vt� L Sewer Tap Deposit.................... $ -64 — <br /> " � TOTAL DEPOSIT ......... $ f 1 <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Al <br /> :ctrr� , <br /> 6 �'cr , c <A .C� r c <br /> Show sketch aboveor refer to drawing submitted <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 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 /> PERMIT. IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER, THE CONTROL NUMBER WILL <br /> BECOME 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 OFAIS PERMIT BEFORE SIGNING. ` � / <br /> Signed: rJ ( �"f_. Phone: -f U7 ' <br /> 1st-Pertnittee (white) 2nd-Inspection (pink) 3rd-File (yellow) 4th-Finance (white) <br />