Laserfiche WebLink
'10/07/2003 15:18 2994677. " _ I� <br /> ' AGE 5TDCI�TDN PAGE 03/0 <br /> CITY OF STOCKTON i, 68168 <br /> I <br /> PUBLIC WORKS DEPARTMENT <br /> M9 APPLICATION FOR ENCROACHMENT ON PU86C R1GHT OF-WAY <br />� ip <br /> nys�awocndi[ ate —Y'.p �,_ APPR0IIED�BY THE PUBLIC WORKS DIRECTOF <br /> n Subject to the General Provisicns and Special Conditions,and all <br /> f Address 7 SV,A,, ) 1Z Phone qui-100(0 wolfs must conform to the projecra approved Storm Water Polluft <br /> City S OC Un State q Zip .95 I FmverWw Plan�or the Ghy of Stockton Storm Water Pollution <br /> PrevenEion Maintenance Staff Guide,whichever is appl'xable. <br /> Location of Proposed Work,etc--./ S0 AlarAlm, W.isor, W&� <br /> Contractor Addressy��e_TP } ..— ByADat9i, <br /> E0mgtfng Startlng Date.. _ _—Completion Date ----� —.,. Permit Expiration Date <br /> / <br /> i I Or We)hereby apply for an Encroachment Permit to carry out the followingr!�wortc: <br /> C/70 <br /> TAert w,'l I h I I2) -b1'phi fQf •�F+keks_e ij 3 dor S <br /> 1 1 l P. [► <br /> -� ! C�---:�e�r Q W 0.�� � ,�,� a 1C1� •1�P __ .�el,�f 1 1 be< �1 e S r3l <br /> ry ' 1 `I- k� 12.. fours t=or int%1, 1 oma .o.,. �i h r s a <br /> i M - <br /> A o r Lan J w 1 F T n S ALS-4. <br /> 1 <br /> 7M et7ew nan,gd aWYCanf hen,byr n3queele pennisafon to- I� �f ` /� ��^ <br /> Mqp CIG A PERMIT FEE------------------------ -$ <br /> I _ <br /> Adtfltl0rt81 Footage Fee <br /> ii <br /> tue ! I Trench Fee..............:................ $ <br /> 1` Sewer <br /> Tap Deposit..--.-...... $ <br /> 6e- �F km ref yr� +0 f�f l�!�fir � 7� TOTAL DEPOSIT.........$ ��� •a <br /> i <br /> Suilding Permit No, <br /> Improvement Plan No. <br /> 0 <br /> Supplemental Conditions: <br /> i <br /> 'I <br /> it <br /> I , <br /> Shaw SkvWh abm or taftr to ftwlna BuffthM i <br /> SII <br /> IIID PORTANT; I <br /> Applicant hereby agrees to comply with all provisions 0}this permit,d9 well as all applicable City Ordinances,resolutions, <br /> Standards and Specifications currently In effect,and to pay m the City Its actual cost for removal and proper replacement of any ROM 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 In)ury to persons,death of ps►son or damage to property occurring at the site <br /> of,or as a resuft Of,work to be performed under this permit A certificate of Insurance shall be subrnItted to'the City Risk Manager prior to Issuance <br /> of this permit- <br /> SHALL CALL(2011)9378366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, <br /> R E START OF WOAic,AND PRIOR TO ANY REQUIRED INSPECTION5,AS IDENTIFIED 6N THE REVERSE SIDE OF THIS <br /> PERMIT.IF WORK DOES NOT BEGIN WrTHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBItA,THE CONTROL NUMBER WILL <br /> BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> SUBDIVISION lMPROVEMiNTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937.8411 FOR <br /> %PECiFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK-) 1 <br /> ,l <br /> READ GENERAL PROVISIONS ON REVERSE 3102 OF IS M EFORE SIGNING. <br /> 4 <br /> i <br /> $iQn9tl �� Prlbne: <br /> tett-Permittee(wma) Inspaotlon(pink) $rd�FRa(yellow) 4041nance(while) <br />