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CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT _ 71919 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name Ady,1vtcea_ 66D 6_A%irv6wlf-4tiL l,KDate APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/C tractor <br /> AddresEIZ111A Phone ')-c`� `� �( Subject to the General Provisions and Special Conditions, <br /> t i and all work must conform to the project's approved Storm <br /> City S�LIL,-Oin State Zip Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work, etc. of the City of Stockton Storm Water Pollution Prevention <br /> Maintena a Staff Guide, whichev r is applicable. <br /> oe <br /> Owner/Contractor Address By Date <br /> Estimated Starting Datel �� Completion Dat e" '( � Permit Expiration Date t—���� <br /> I or We) hereby apply for an Encroachment Permit to carry out the following work: / <br /> AoAce- +�1 f v_ ((� 1 �5c to <br /> T <br /> t� <br /> a1 Jo ✓tilv,�� <br /> ATTENTION: Applicant/Contractor—you are responsible to <br /> replace all broken, damaged, and/or raised sidewalk, curb and PE T FEE........................... $ _ <br /> gutter from score mark to score mark adjacent to the parcel: e G C-� 2 <br /> remove USA markings upon completion of the permitted work. na o ag oFee .......... $ 3 <br /> The above named applicant hereby requests permission to: Y{ <br /> Sewer Tapf5eposit.................. $ <br /> TOTAL DEPOSIT ....... $ 2 <br /> = mit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> �v <br /> PERMIT NOT VALID WlTNOUT A <br /> CONTROL NUMBER, <br /> CALL (209) 937-&W TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF K. <br /> 72 HOURS PRIOR TO START OF MR <br /> Show sketch above or refer to drawing submitted CONTROL.,# <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: Phone: <br /> iSt -Permittee (white) 2n11 -Inspection (pink) 3rd -File (yellow) 4111 -Finance (white) <br />