Laserfiche WebLink
09 / 04 / 2002 14Y09 2094671 " AGE STOCKTON PAGE 02 <br /> Sep 04 OZ 0 39P C _ . y of SteektonPW - Permit ( EL _ J937 - 8901 p41 <br /> M s,� mo� 93 <br /> CITY OFSTOCKTON <br /> f PUBLIC WORKS DEPARTMENT q9 ®4 <br /> i. M15 APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF=WAY <br /> ADp9cairsName AA� VZIGODCAviwnPten'tats V4 - 01 -o2 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> I (rdwom/Contracto� <br /> i (�o1J Subject to the General ProWalons and Special Conditions, and all <br /> Address y63 � � „ORo� Phone � (07 - I �pl� work roust conform to ft project's approved Slorrn Water Pollution <br /> City }G�.1C-Fmt State CR Zip ` 5 Z lS Prevention Plan or me city of Stockton Stone Water Pollution <br /> n Prevention Mainter>ence Staff Guide, whichever Is applicable, <br /> Location Of Proposed Work, etc. <br /> y es Tac ,- F; r_l�venue 9- y -o Z <br /> Owner/ Contractor Address01 <br /> B DatalQf '�- <br /> Estimating StaningDate , ' v Completion Date Ormlt Expiretlon Date z�- /-o � <br /> I (or We) hereby apply for an DEncroachment Permit to carry out th[g� foll�towl �7fg work: f I Ma rrn � <br /> w�IIS � nG C)f1 �25�- MAr14 �� c`YLG aLOrX aChPC 011 JUl"iM '�' dS <br /> no enwe named apmlcem nereey reaueae narmhamw n - <br /> ,,� " t PERMIT FEE ....... .... .... ......... .... $ 1 <br /> ReFer- 1 (l a*acke & SAL ae) Additional Footage Fee .... .... $ _ <br /> TrenchFee .. ... .... .... .................. $ <br /> SewerTep Deposit..0 0+d r t;I &%I r I I I P%1 $ <br /> ` TOTALDEPOSIT .,.. .... . $ ' <br /> Building Permit No. <br /> El Improvement Plan No, <br /> 8upplemantal Conditions, <br /> � t o . Sl&')al�- rZ, Ca. sv - v <br /> show skeknabava crme rtodrawhp submRrae <br /> IMPORTANT: Applicant hereby agrees to Comply with all provisions of 6a permit, as well as all applicable qty ordinances, resolutions, <br /> Standards and Specifications currently in effect, and to pay to the " Its actual coat for removal and proper replacement Of any Hem which doge <br /> not meet the above requirements. Fallure to comply wlil be cause for revooallon of permit Applicant agrees to Indemnity and hold the City <br /> harI against any and all losses, costs, or damagas resulting from Injury to persons, death of person or damage to property occurring at the site <br /> of, or as a result of, work to be performed under this permit. A certificate of Insurance shell be submitted to the City Risk Manager prior to Iseuanos <br /> of this permit. <br /> PERMITTEE SHALL CALL (209) 937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS, BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE START OF WORK, AND PRIOR TO ANY REQUIRED INSPECTIONS, AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT, IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER, THE CONTROL NUMBER WILL <br /> BECOME INVALID AND THE PERMITTEE SHALL CALL FOR ANEW CONTROL NUMBER. (FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION IMPROVEMENTS, PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT (209) 937.8411 FOR <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF I ER�W BEFORE SIGNING. dI^� �y <br /> 9lgned: Phone; d [�j' <br /> � YV 7�I � <br /> Isl PennRtse (wWle) d-Inspeolon (elide) and-Rle (yellow) 4eh-Flnenoe (white) _ <br />