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CITY OF STOCKTON <br /> \\ PUBLIC WORKS DEPARTMENT 73132 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name olaHt-n Date 8/1,4/07 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor] �— <br /> Address S.21 S4_..­ZSL,,4e.3Cd Phone&`S­614(-4ocrl Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City State Com_Zip 44s-£'S Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work,etc. '�ACnd� }a of the City of Stockton Storm Water Pollution Prevention <br /> Maintenance Staff Guide,whichever is applicable. <br /> yo�ci�ic f�1r.w ���g a 0632 S'ot}�1� .dyr3A,kr <br /> Owner/Contractor Address ByDate <br /> Estimated Starting Date &N(09 Completion Date 6/te/017 Permit Expiration Date <br /> I(or We)hereby apply for an Encroachment Permit to cavy out the following work: � -S we'1 <br /> I 3t_ 4 2 3 <br /> ATTENTION:ApplicanVContrector–you are responsible to 2-3p„ <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; rff g �3 <br /> remove USA markings upon completion of the permitted work. Additional Footage FeeCe� <br /> The above named applicant hereby requests permission to: 7 t� <br /> Sewer Tap Deposit...............G $ l <br /> TOTAL DEPOSIT ...... $ 57 <br /> Building Permit No. <br /> Improvement Plan No. <br /> -Supplemental Conditions: <br /> PERMIT NOT VAW WITHW A <br /> CONTROL NUMBER. <br /> CALL (208)937.M TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> /E�X/CCESSSS O/FF 72 SOF K <br /> Show sketch above or refer to drawing submitted i/�,/r�IRVI.N TART Imo• v ��O <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 SHALLCONTACT 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)9374381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMITBEFORE SIG ING. <br /> Signed'- Phone: <br /> 1sr-Permittee(white) 2nd-Inspection(pink) 3rd-File(yellow) 411-Finance(white) <br />