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CITY OF STOCKTON '74062 <br /> PUBLIC WORKS DEPARTMENT ►1� (���� <br /> S APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-0��V <br /> Applicant's Name �Fc ,> uv Date�� �21 APPROVED: �lfiiz41 �U419 du(HBIKS DIRECTOR <br /> (Owner/Contractor) 1 p S�c-(VQ p %O <br /> U <br /> Address Rl"7, �n-+�-> YG[�a61.� Phone orb Subject to the Gentg�q �r{d[fiA, Conditions, <br /> 1 �� /7 and all work must co tW�q) t�roved Storm <br /> City -� ✓I State l Zip Water Pollution Prevention Plan 6r��t'�({{��tt4�v current version <br /> of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work,etc. 5,Oekw Mainten nce Staff Guide, whichever is applicable. <br /> Owner/Contractor Address 3)(a /U, ELt�y �g�( , pcj /By Date C G�(0 <br /> Estimated Starting Date &07/m h J Completion Date d����D L l Permit Expiration Date <br /> I (or We)hereby apply for an Encroachment Permit to carry out the following work: <br /> Ins Ll A: weld <br /> Kill <br /> ATTENTION:Applicant/Contractor—you are responsible to <br /> 7 7 <br /> C/J Oli <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ <br /> gutter from score mark to score mark adjacent to the parcel; 3 Z <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $ //(/ <br /> The above named applicant hereby requests permission to: �/j <br /> Sewer Tap Deposit.................. $ <br /> TOTAL DEPOSIT ...... $ J� Z <br /> qq t,;le e_p ly <br /> Bntldim Permit No. <br /> Improvement Plan No. <br /> /) Supplemental Conditions: <br /> ER IT NOT VAUD WITHOUT n. <br /> CONTROL NUMBER. <br /> CALL (209) 937.8386 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT <br /> JC <br /> EXCESS OF 72 HOURS PRIOR TO START OF%WW <br /> ONTROL#,—s_._-- - .- <br /> Show sketch above or 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 <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 certificate 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 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 SPECIFIC <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)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 SIGNING. <br /> Signed: U.7(.l40l,")2 Phone: 6�67lob6 <br /> tst _PormittAA(whitPl 9nd-Incnortinn (nink', qrd_Fila lvollnm,t Ath_Fi"nro/ruhitol <br />