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03/24/2003 14:46 2094671118 AGE STOCKTON PAGE 04 <br /> y 67774 <br /> CITY OF STJCKTON <br /> PUBLIC WORKS DEPARTMENT <br /> M9 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-Oli <br /> M5 <br /> Applicant's Name <br /> f� ��b Date `z`r-- APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> towner/Contractor) )9 ��67 l (� Subject to the General Provisions and Special Conditions,and all <br /> Address r= Phone 1" work must conform to the project's approved Storm Water Pollution <br /> Prevention Plan or the City of Stockton Storm Water Pollution <br /> City State — zip !H2 r prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc. <br /> � C- 6Y / Date <br /> Owner!Contractor Address a? S r <br /> Estimating Starting Date <br /> 3 Al COrnpletlnn Date Permit Expiration Date <br /> I (or We) hereby apply for an E=ncroachment Permit to carry out the following work: �i��� <br /> _>T z cl�,� - S 1 K—rTv+E' V <br /> Tia above named snaacan:he-eby-epueeits permission tb- PERMIT FEE - $ <br /> Additional Footage Fee - $ <br /> Trench Fee............................... $ <br /> Sewer Tap Deposit............,....,.. $ <br /> /2 0 <br /> TOTAL DEPOSIT.........$ J <br /> Building Permit No. <br /> Improvement Pian No. <br /> Supplemental Conditions: 0. f Prr <br /> A!n y 11-- C P6 0.el A-9 coo <br /> Show sketch above or rdfor to drawhig 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 Speclflcatlons 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 propeny occurring at the site <br /> of,or as a resuff of,work to be performed under this permit-A Certificate of insurance shall be submitted to the City Risk Manerger prior to issuance <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 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 PERMIT BEFORE SIGNING. / / d <br /> Prone, <br /> 3rd-Fila(yellow4th-Finance(white) <br /> let-Permittee(white) 2nd-Inspection(pink) (Y ) <br />