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L`. LV'.'J i Li^ vv ,�v :v. �'-'J. 9JV'I [. L <br /> CITY OF STOCKTOm 69303 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name caAr Date :, APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/ rp �" ' Subject to the General Provisions and Special Conditions, <br /> Address��U st 4sAI Phone and all work must conform to the project's approved Storm <br /> City 51CA,>\ State zip Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. W, r;, --A s. of the City of Stockton Storm Water P Ilution Preventlon <br /> Mainte ce St Guide,wh' eV is applicable. <br /> Owner/Contractor Address N e tj 1)6oe By Date <br /> Estimated Starting Date Z—'Z?_,c>6 Completion Date 7-Z 9—Uri _ Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: GrzDjUjtz_ <br /> in <br /> w-- mowJi <br /> �i �lt1t Fi'iiJ.,- y. V err),&_ A_i_ -- <br /> �- l0 Ira, <br /> ATTENTION:Applicant/Contructor—; ul� ,asponsih;�to B. — <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE. ......................... $ <br /> gutter from store mark to score mark adjacent to the parcel; <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee---------- $ r <br /> Tile above names applicant nereby requests permtsalon to: <br /> Sewer Tap Deposit.................. $ <br /> TOTAL DEPOSIT ...... <br /> S <br /> �6 Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> PERMIT NOT VAUD VATHOUT A <br /> S/_ CONTROL NUMBER. <br /> ( � CALL (209) 93748386 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> f <br /> tocm f EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> CONTROL <br /> Show sketch above ae refer to drawing a iittee <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 <br /> does not meet the above requirements. Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnify and hold <br /> the City harmless against any and all losses,costs, or damages resulting from injury to persons,death of person or damage to property <br /> occurring at the site of, or as a result of,work to be performed under this permit.A certlflcate of Insurance shall be submitted to the City Risk <br /> Manager prior to issuance of this permit. <br /> IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OFA 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 SPECIFIC <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANYWORK,)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE <br /> SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937-8381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNI4:�&Phone: <br /> G <br /> Signed: " "` Z69-231—C619' <br /> 1"-Permittee(white) 2n1i-Inspection(pink) 3fd-File(yellow) 41h-Finance(white) <br />