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S CITY OF STOCKTON 10 6 7 5 7 9 <br /> PUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name CbNaoR ttiFINOLo(aIGS Date t 4 off` APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) T <br /> I$9 Fw,t+K WESI-4�. S U ITE ,1 O Subject s the General Provisions and Special Conditions,and all <br /> Address 1 PhonOet234' �� work must conform to the project's approved Storm Water Pollution <br /> City STDL MIJ Stale� Zip 206 Prevention Plan or the City of Stockton Storm Water Pollution <br /> Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc. SIOElN A4x ON EIkT 519E ,O't� S. ' <br /> AMactcnN S REEL goweEN E. Ma1u Sr_ Ary 6-MAU-erS'[ // <br /> Owner/Contractor Address By ` Date /�—�Z-O Z <br /> Estimating Starting Date 1111810-L- Completion Dale 1 I'2 210 L Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: At DVANc.1% y SOIL <br /> !Sot-laLni 'ro *3Df AND oNC Solt_ VJ' N(7 "To 'J'1 IN 9-JAE SIIh6(.rA-LK onl <br /> 6W St ba✓ 6F S• &M<-PAC" SVZ-6'r DP(I. E-6V C ,MAVJ Sme� AND F, <br /> AAAjl StLeC-r- <br /> f}II Wank 5Akl/ wit641 1-k '5'/l.✓ <br /> The above named applicant hereby requests permission to <br /> PERMIT FEE............................$ J <br /> Additional Footage Fee............ $ <br /> Trench Fee............................... $ <br /> Sewer Tap Deposit.................... $ <br /> 1 � <br /> TOTAL DEPOSIT.........$ / � '—a— <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> paah c�e4 S/w Shall �� IPPi-/a cpv� <br /> PP001 Scolze r1^Prek to SCo�c �"IA^K <br /> h 11' V54 M chrk"/ NK f s'1,a// 'eP <br /> IV/ax conolewo <br /> Show sketch atwve or rotor 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 indemnity 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 /> RMIT.IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> OME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> DIVISION 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 OF THIS�ERMIIITT/BEFORE SIGNING.G� T <br /> Signed ` V` /�-- DOR 6kILM 160H, Phone: 9- 2-3 y�ung <br /> 1st-Pennitlee(while) 2nd-Inspection(pink) 3rd-File(yellow) 4th-Finance(white) <br />