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INECENED <br /> S • CITY 01` STOCKTON -S,2osZ635 6 <br /> 11 <br /> PUBLIC WORKS DEPARTMENT NOV 1 9 7007 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY feu o�21Lv <br /> �+ e. ENVIRONMENT HEALTH <br /> < <br /> Applicant's Name r E %L116, Date �� �`l APPROVED: BY THLEFRIN11I11V6L*11154CS DIRECTOR <br /> (Owner/Contract <br /> Address—0 4dwidl Sf !2''`/' 2q Phone 514-c51"J35 Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City or 11, State GA Zip �/9 6Dfl Water Pollution Prevention Plan or the most current version <br /> ( of the Cit of Stockton Storm Water Pollution Prevention <br /> Location of P posed ork, etc. 7e�vkty /&,1 4'* foma/' Maintenance Staff Guide,whichever is applicable. <br /> �^/ <br /> lift e tr �sw", � Byractor �An / ond <br /> Estimated Starting Date ompletion Date I 0 O Permit Expiration Date <br /> I (or We) herebb�y apply for an Encroachment Permit to carry out the following work: <br /> /=t <br /> ,-r- 2 ovvi-t nVt/ <br /> e{q.f r, flG r Z1%7 CSO/ /� S{ <br /> tt <br /> eef <br /> J'A7v h4dry. <br /> 7 <br /> ATTENTION: Applicant/Contractor—you are responsible to Z � <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; _.d. <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee .......... $ <br /> The above named applicant hereby requests permission to: $ <br /> Sewer Tap Deposit.................. <br /> TOTAL DEPOSIT ...... $ 3!T L <br /> Building Permit No. <br /> D A Improvement Plan No. <br /> l Supplemental Conditions: <br /> PERMIT NOT VALID WITHOUT A <br /> CONTROL NUMBER, <br /> CALL (209) 937-8366 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> CONTROL# <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: r�/1 t��f111ane: s�0- 6S7 41Sol7 <br /> 151 -Permittee (white) 2nd -Inspection (pink) 31d -File (yellow) 41h -Finance (white) <br />