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Permit Number <br /> 5CITY OF ENCROACHMENT PERMIT N" 7767 1 <br /> STOCKTON C!- <br /> Applicant: � U I ON PUBLIC RIGHT-OF-WAY <br /> T��` YJ 1 Date: ! } APPROVED:BY THE DEPARTMENT DIRECTOR <br /> I I � � <br /> 1 Z Subject to the General Provisions and Special Conditions,and all work must <br /> rn �` 0 conform to the project's approved Storm Water Pollution Prevention Plan o <br /> Address: 1 l�� 111000..��i` �lisR L. the most current version of the City of Stockton Storm Water <br /> A A c � PollutionlPrelv/entiio/n Maintenance Staff Guide,whichever is applicable. <br /> City: �_\��5� State: /'l ZIP: �J t V2221 9 v v�`� �� Date: <br /> 91 ZL W y: <br /> Phone:20 � � E-mail:E-mail•C1ene,�2.nl� �' <br /> .f' ln '�Cllnt)• � - <br /> ssociated Permit(s): Expiration: <br /> / - tenor n/t`�n A <br /> WORK LOCATION:-7GLi CbC ttyL. Ave, <br /> Start Date: Completion Date: br 2p���� <br /> ATTENTION:Applicant/Contractor-you are responsible to replace all broken,damaged, <br /> and/or raised sidewalk,curb and gutter from score mark to score mark adjacent to the <br /> parcel;remove USA markings upon completion of the permitted work. <br /> I(or we)hereby apply for an Encroachment Permit to carry out the following work: <br /> 4 )d6 mfi,�R*t A fir -k1b41 'i ' -c t wc—mc�4 of IRiveoL QA alr� t0-CIF & h C <br /> c��r 4�(cCb`t1r.o�c�on�c�►-to f .S 12c� ,r. e c,�, S �yn's nab.`'- t-t„ r sem -au►rl <br /> Show sketch or refer to attached Drawing <br /> Official Use Only <br /> Base Permit Fee � � .00 <br /> Cx� Additional Footage Fee $ iI <br /> Misc. Ew $ 3`► ti3 <br /> Misc. M5 $ <br /> Misc. $ <br /> Total Is 5 Z• 1 <br /> Special Conditions: <br /> =F,QT\- (� Sokt--1 Ur1 r c li <br /> I2gZ- <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 <br /> PERMIT,PERMITTEE SHALL CALL INSPECTIONS AT(209)937.8381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE <br /> SIGNING. Print �Z <br />