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CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT C�'`t Q <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> as i� Date 3 /12 /07- <br /> Applicants APPROVED. BY THE PUBLIC WORKS DIRECTOR <br /> Name � n i <br /> (Owner/Contractor) Subject to the General Provisions and Special Conditions,and all <br /> Address 314o Gild �T 5u f Phone `116—63(-1� work must conform to the project's approved Storm Water pollution <br /> Prevention Plan or the City of Stockton Storm Water Pollution <br /> City Q&Arha cor ova State GA zap qPrevention Maintenance Staff Guide,whichever is applicable <br /> Location of Proposed Work,etc 3� �1ad` GSI tgo,n1n <br /> k:::Owner/Contractor Address B Date <br /> Estimating Starting Date 110 192. Completion Date -1-z 1a *ermitxpiration Date '©�^ <br /> I (or We hereby apply for an Encroachment Permit to carry out the following work <br /> Til_ t- u.. <br /> C <br /> The above named applicant hei by requests permimm to <br /> PERMIT FEE $ <br /> Additional Footage Fee $ �O <br /> i � Trench Fee $ <br /> oil <br /> Q Sewer Tap Deposit $ <br /> FvRHER VN,0"L <br /> I I TOTAL DEPOSIT $ <br /> N <br /> 437 F M INER AVE rl Building Permit No <br /> CM <br /> �I Improvement Plan No <br /> i N <br /> Supplemental Conditions <br /> t�sT 'MrN��. A <br /> show sketch above or reler 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 Indemnify 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)937-6366 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 /> �ERMIT IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> ECOME 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 <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK) <br /> READ GENERAL_PROVISIONS ON REVERSE SIDE OF= FORE SIGNING <br /> Signed Phone i t- 31t- r <br /> ist-Perminee(wtdte) 2nd-Inspection(pink) 3rd-File(yellow) 4th-Finance(white) <br />