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~ CITY OF STOCKTON <br /> 71914 <br /> SPUBLIC WORKS DEPARTMENT <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> //�� �a r( t \ <br /> Applicant' a f-tl�1)GL E(� tAf n� �+ate APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner ontracto L4 �'_(O� Subject to the General Provisions and Special Conditions, <br /> Address Lt w Phone and all work must conform to the project's approved Storm <br /> City sN-D[ V-A-OYI State L^-(A _Zip 5Z\S Water Pollution Prevention Plan or the most current version <br /> of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. 1'2 7 `G • N,A- ✓' A t)eywe- Maintenance Staff Guide, whichever is applicable. <br /> t n h Lrti�b��.r if wog\\� 1�t 1 y oF51 kAb i C <br /> 6t SoNr,s �ptYG-ngT� / Date <br /> Owne ontractor Address T!, t +� a-A -��r2e t RY / <br /> Estimated Starting Date:J%IV�P 2. . Dpi Completion Date �Uhe t \� Permit Expiration Date 7 'lJ ' � <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> F,vo nr 1\\Thr PSIS R-\ R-2, R-y ��dl f�- S \ze- vlf <br /> n Y, `��5� S r4 F Nv✓11 etr C�re�'r <br /> ATTENTION:Applicant/Contractor-you are responsible to OO <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ <br /> 3 38 gutter from score mark to score mark adjacent to the parcel; <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $ <br /> The above named applicant hereby requests permission to: $ <br /> p Sewer Tap Deposit.................. <br /> TOTAL DEPOSIT ...... $ <br /> Building Permit No. <br /> Improvement Plan No. <br /> 9\Supplementalontions: <br /> A N co/,I yam '11"W" <br /> PERMIT NOT VALID WITHOUT A <br /> CONTROL NUNIIIER. <br /> CALL (209) 93744 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF72 HOURS PRIOR TO START OF WORK. <br /> Show sketch above or refer to drawing submitted CON t RRL# <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 FORE SIGN f <br /> Sig a Phone: <br /> 1st -Permittee (white) <br /> 2nd-Inspection (pink) 31d-File (yellow) 411-Finance (white) <br />