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CITY OF STOCKTON PUBLIC WORKS DEPARTMENT 74449 M5APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY Applicant's Name AhyaOegi f MFnl1?yt+1yNjjt1.IlX Date Id/a701-►D APPROVED: BY THE PUBLIC WORKS DIRECTOR (Owner on Address_837 9hdu1 Rn�id Phone 209- SIL 7-IUO� Subject to the General Provisions and Special Conditions, and all work must conform to the project's approved Storm City g} dk-ft)rt State Com_Zip 9S21S Water Pollution Prevention Plan or the most current version Location of Proposed Work, etc. of the City of Stockton Storm Water Pollution Prevention P nrk ina Ldn� nn �atF 4 cL.0 !,v\r..�1 nQ� Maintenance Staff Guide,whichever is applicable. APOJ,K 260'Naf usai#S Are. And Ode t11111c arta 0; i,nD9 Unr�1n �}►�� _/O Owner/Contractor Address ByGF%G �Date/� Estimated Starting Date J- /—// Completion Date Permit Expiration Date I (or We) hereby apply for an Encroachment Permit to carry out the following work: v U ' 14 I i t r rt l l eA NOri-kb n3 C QtW g OU�hba.�n VE'�ric..\e. tiny 110 S. %ihralrt St. Rta wi'dt paepjtet ivilb 44u IZQW, howeyevAbaffi-t Shad noE be hlenked -U�wwuagrt ym1\ Q wi)Nn t)y\Livicolvi 3t-. 4Au Ci_e wak- lo(nlea on .&P pAs r'LAP 1,nen\h al WiV be Mcfed PedPS-F an jmf-L- N6ykyt of abAs pr"Uj ATTENTION:Applicant/Contractor—you are responsible to ^7 p o replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ G gutter from score mark to score mark adjacent to the parcel; Z remove USA markings upon completion of the permitted work. Additional Footage Fee.......... $ -37 The above named applicant hereby requests permission to: Or LC Sewer Tap Deposit.................. $ l �9 TOTAL DEPOSIT ...... $ S �l ease See a,�40 e h.ed Building Permit No. Improvement Plan No. ma,p Supplemental Conditions: PERMIT NOT VALID VATHOUT A r,ONTl9OL NUMBER. (209) 937-83136 TO REQUEST A CONTROL ,*J*iBE:R NO LESS THAN 24 HOURS, BUT NOT IN =XCESS OF 72 HOURS PRIOR TO START OF Y°CRK. " 7'r`()L# 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 this permit.Applicant agrees to indemnify 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. IF THE WORK DOES NOT COMMENCE 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.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937-8381. READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. Signed: — Phone: - �S; D-.miffnn lwhitol Ind _Inennnfinn /ninL\ )rd Gil- /vnll-.u\ nth Ci-nn-- /...hih-\