Laserfiche WebLink
CITY OF STOCKTON 69988 <br /> PUBLIC WORKS DEPARTMENT ,- <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> E r.v.ruc�Mw�ro.S< <br /> Applicant's Name ` Date i o Z-1 ov APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> wn /Contractor) ���� �� f_ �yy <br /> � � Subject to the General Provisions and Special Conditions, <br /> A ress w�� �0\1 n�.u �nya c Phone �� 3i a and all work must conform to the project's approved Storm <br /> City State c-A Zip�\LkSSs 3 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 /> p S c� w��\� \ocof Maintenance Staff Guide, whichever is applicable. <br /> c�nA <br /> �-�. <br /> Owner/ ddress \0` 10 �A By Date <br /> Estimated Starting Date \11 kbjci k. Completion Date /_/t0 _7 Permit Expiration Date 1_31 _0Z <br /> 1 (or We) hereby apply for an Encroachment Permit to carry out the following work: ik&),, "- r - gngid,J<: <br /> Soy 1 \4[�J Cr r,r\ - 0N-_2 ��e\�� \-a �\ ��� CSir vra coca cl acv s , r. <br /> C' <br /> �1 <br /> / S' e' P/f/q J r s eve A /YL <br /> ATTENTION: Applicant/Contractor-you are responsible to do <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ <br /> gutter from score mark to score mark adjacent to the parcel; <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee .......... $ <br /> The above named applicant hereby requests permission to: ~ <br /> Sewer Tap Deposit.................. $ z <br /> adv c,.�-•c� �- `_� v: � d v.,..J S - �c..�sl- �JI ��- <br /> TOTAL DEPOSIT ...... $ <br /> ei/2c.4le p u i 2 c. <br /> Permit No. Ot�-/3 IV <br /> Improvement Plan No. <br /> R ` ( Supplemental Conditions: <br /> PERMIT NOT VALID WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 937-8366 TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK, <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 /> 1)E Q�s.D.S� M o.:,+, Q�„r�:,.�e- �.o•?J�s� e_srv��o,c�roe'. <br /> Q�\o,S\G• CN8' Signed: Phonek� llo SC�� -oiL <br /> k,tsqu-' %c1+-10 old pt�.Cz �v':�\� VIA <br /> 151 Permittee(white�)Q �� L, 2"d-Inspection (pink) 3rd-File(yellow) 4" -Finance (white) <br />