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CITY OF STOCKTON � � 6 7 9 5 2 <br /> S PUBLIC WORKS DEPARTMENT <br /> S APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Pp <br /> ilicanVs Name QbnoaTh I Ib1z Datea b3 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> COwner/Contracttor) Subject to the General Provisions and Special Conditions, and all 1 <br /> ressltf R1�1a Phone'li(P-fib' Gt[�33 work must conform to the project's approved Storm Water Pollution <br /> City c%rzV(AY0tA n it StateZip V/ J'lJ� Prevention Plan or the City of Stockton Storm Water Pollution ,m <br /> h _ Prevention Maintenance Staff Guide, whichever is applicable <br /> Location of Proposed Work, etc. . a <br /> Addres By Date /0- 703 <br /> Estimating Starting Date ' �/- Completion Date Permit Expiration Date <br /> © 1 <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: � 11d �GI� ArmC-Lvr[GILLLT W <br /> aj%imbotr 111001tOrrIVIC W019 <br /> S - 0 , Nt416 W1 I I JrX M m of- a aFYAIIQ ' IUlf a IU ` Scre • �sll SuJ�f <br /> 1 S VS01V - <br /> V00 f <br /> �i In DI <br /> o vrs x'. fi �I i i 11 A c <br /> �tOWGU>IWt 0. Q2D1Stt) llts[ Vcttn , ufs� Irrl7{AfJ � eolsivo ham mer OntltIng quipwrl <br /> The above named applicant hereby requests permission to - 9170 <br /> p011 (� .� /� 61^ /teC� � [i [ PERMIT FEE . . . ........:.:.......... .... $ <br /> Additional Footage Fee ............ $ <br /> Trench Fee ......... . . ....... ............. $ <br /> Sewer Tap Deposit.. I....... $ <br /> TOTAL DEPOSIT ...... ... $ <br /> uff/ 1V1I`Kga* - <br /> Building Permit No. <br /> Improvement Plan No, <br /> Supplemental Conditions: <br /> Sem RP 03^ Z �✓ <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 does <br /> not meet the above requirements. Failure to comply will be cause for revocation of permit. Applicant agrees to indemnify and hold the City <br /> 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 <br /> 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 <br /> of this permit. <br /> PERMITTEE SHALL CA ;NO <br /> 9) 937-8366 FORA ONTROL NUMBER NO LESS THAN 24 HOURS, BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE STARTRK, AND P ANY REQUIRED INSPECTIONS, AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT. IF WORK DOES IT <br /> 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 <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SIDE OF THIS PE MIT BEFORE SIG�NIjN�G�.J1 <br /> Signed: &41 w Phone: <br /> \ 1st-Permittee (white) -inspection (pink) 3rd File (yellow) 4th-Finance (white) <br />