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1 <br /> 011kITY OF STOCKTON <br /> ttC Wt7RfC�DEPAR7MENT 74763 <br /> MS mos APPLICATION FOR ENCROACHMENT ON PIUBLUC R GHT-OF-WAY�� <br /> Applicant'sName �- r. !"7 �,GY 1-C Date `� �/ APPROVED: BY THE P�H$tle-W0RKc DIRECTOR <br /> (Ownmenrew <br /> r) ,,tt,,,,,,Addrk.OLJ/9%� (.7k�9Ps Phone&5— 1��" lcl� Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City V k State ip _ Water Pollution Prevention Plan or the most current version <br /> of the City Stockton Storm Water Pollution Prevention <br /> Location of Propo ed Work, etc. �q�� �j L � Mainte a Staff Guide, whichever Is applicable. <br /> Jusf r e w r ad <br /> Ow ontractor Address �d47 By Date / < <br /> i <br /> Estimated Starting Date S Completion Date L(0 Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: 0 KV- v' l J!m' i— <br /> +"d t l to DCR D h l✓ Vl {� cle- lY <br /> �� w� (� ,.� -rpt �• �I �'� -r�a•f- ! �i � !• <br /> ala d "ji 44 <br /> �evem ilyllii 4st sarrvwadj' evv'! once, <br /> - V6 As, c✓6_ L V1 _h-_S �" �,`r� if <br /> ATTENTION:Applicant/Contractor-you are responsible to � p o <br /> replace all broken, damaged, and/or raised sidewalk, curb andPERMIT FEE....................... $ _ <br /> gutter from score mark to score mark adjacent to the parcel; 3 7 Z 3 <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $ J 'A <br /> The above named applicant hereby requests permission to <br /> Sewer Tap Deposit.................. $ <br /> TOTAL DEPOSIT ...... $ S �' <br /> Building Permit No. <br /> Improvement Plan No. <br /> Sup 4 Pal Conditions: <br /> O1 - 0-Z <br /> PERMIT NOT VALID WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 9374338f3 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 FOURS, BUT NOT li• <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> GONTROLJ___..._...... ..._�-�w.......�_._.zr ... <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 indemnity 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: _ Phone: (05 j� _= 7 <br /> 1s'-Permittee(white) 2nd -Inspection (pink) 3111-File(vellow) 41h-Finance (white) <br />