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CITYOF EWROACHMENT PERM EN2 <br /> 7Number <br /> ON PUBLIC RIGHT-OF-WAY <br /> µanTOCKTON ����+. + yy <br /> Applicant:l Jt�1. Mel) s ,),EAUj V/I�jdy(W Date: - "f '� J APPROVED: BY THE DEPARTMENT DIRECTOR <br /> [ y0 Z1he <br /> ubject to the General Provisions and Special Conditions,and all work mus <br /> Address:_ / S(/aw '�Lf . �` - �, 0onform to the project's approved Storm Water Pollution Prevention Plan o <br /> most current version of the City of Stockton Storm Wate <br /> �� Pollution Prevention Maintenance Staff Guide,whichever is applicable. <br /> City: — (-' State: ZIP: Q <br /> 0 ) E-mail: Iam 0- <br /> Phone: <br /> 'W� <br /> Date: <br /> / <br /> Qh -CV 9 [Associated Permit(s): Expiration: 121I <br /> WORK LOCATION: Got Ea5f A'la I <br /> Start Date: IC/'-I6 "J� Completion Date: -" <br /> x20914 '27-W% TO`45 ak nrr� XV 4_i`�L <br /> !' <br /> ATTENTION:Applicant/Contractor-you are responsible to replace all broken,damaged, 41.RN".� � =wl2<5 " ;1114, WT MOT N <br /> and/or raised sidewalk,curb and gutterfrom score mark to score mark adjacent to the �.Yi4' s� a,��"�.U`JRS M STS X <br /> parcel;remove USA markings upon completion of the permitted work. 14*TK4Y, <br /> I(or we)hereby apply for an Encroachment++Permit to carry ut the follow' g work: <br /> �pj.l ��{)'1C r I > UCF41 Qr o.e U/-1 C4 t. <br /> VJe <br /> V)�KQEIAAR, 1 4 'l N, W I I l C V V mil. �lt��✓�'` 44e, 'Do] rl?f <br /> Show sketch or refer to attached Drawing- - <br /> Official Use Only <br /> ��eoP rfe 1/G�, Base Permit Fee $ <br /> � uaA� ��J, / f��wj Sv(a6le Additional Footage Fee $ <br /> V r St�l�' Pte C C?bCo ` v� o Misc. $ 3q.2,3 <br /> Misc. $ 11 <br /> Misc. $ <br /> Total Is <br /> Special Conditions: <br /> CSU-- PV11 1I"SSpecTD(Z, FO12. <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit, as well as all applicable city ordinances, resolutions, Standards and <br /> Specifications currently in effect, and to pay to the City its actual cost for removal and proper replacement of any item which does not meet the above <br /> requirements. Failure to comply will be cause for revocation of this permit. Applicant agrees to indemnify and hold the City harmless against any and <br /> all losses, costs, or damages resulting from injury to persons, death of person or damage to property occurring at the site of, or as a result of, work to be <br /> performed under this permit.A certificate of insurance shall be on file with the City Risk Manager prior to issuance of this permit. <br /> IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE <br /> OF A CONTROL NUMBER, THE CONTROL NUMBER WILL BECOME INVALID <br /> AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER. PRIOR TO � <br /> ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS _Sign / l�� <br /> PERMIT,PERMITTEE SHALL CALL INSPECTIONS AT(209)937.8381. - <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE t <br /> SIGNING. Print �,r��/�1�� <br />