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CITY OF STOCKTON O n PUBLIC WORKS DEPARTMENT MS ►J M57M APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY A plicant's Name C� +�, leir �' � I APPROVED: BY THE PUBLIC WORKS DIRECTOR !Owner/Contractor) 1 Subject to the General Provisions and Special Conditions,and all Address 1 9� r l T1 fr't � !lJC!��f��rG�P� one 2 `4�-0 � work must conform to the project's approved Storm Water Pollution city sfio c'�C1'-n V_% State _ Zip 9 S 6(c, Prevention Plan or the City of Stockton Storm Water Pollution j —�-- Prevention Maintenance Staff Guide,whichever is applicable. Location of Proposed Work,etc. i'U.r i< � U Owner/Contractor Address J �,a „ ;�'�,� AEBy �4c ),4--cateEstimating Starting Date Ff� jC� O� Completion Datemit Expiration Date �� Z I (or We) hereby apply for an Encroachment Permit to carry out the following work: —f ; aA 012 The above named applicant hereby requests permission to- O PERMIT FEE ............................$ Additional Footage Fee ............ $ $' TrenchFee............................... $ Sewer Tap Deposit........... ........ $ Q' 067 TOTAL DEPOSIT.........$ a Building Permit No. Improvement Plan No. Supplemental Conditions: Show sketch above or refer to drawing submitted IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit,as well as all applicable City ordinances, resolutions, Standards and 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 requirements. Failure to comply will be cause for revocation of permit.Applicant agrees to indemnity and hold the City harmless against any and 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 performed under this permit.A certificate of insurance shall be submitted to the City Risk Manager prior to issuance of this permit. PERMITTEE SHALL CALL(209)937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS, BUT NOT IN EXCESS OF 72 HOURS, PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT. IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER. (FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937-8411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) READ GENERAL PROVISIONS ON REVERSE SID HIS PERMIT BEFORE SIG NG. 9 l9�1A r // Si ned: �I;F— Phone: 1st-Permittee white �FiY S (white) 2nd-nspectio k) 3rd- ile(yel wj L 4th-Finance(white)