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- - - <br /> CITY OF STOCKTON 68168 <br />' PUBLIC WORKS DEPARTMENT <br /> • APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> (Own a� dc7 Cir ;•ti i~t�ri late -�-C�3 APPROVED: BY THE PUBLIC WORKS DIRECTOR <br />' (Owne ontracto <br /> L, Subject W the General Provisions and Special Conditions,and all <br /> Address �a�y r� -_Phone 7 �]- CSG. work must conform to the project's approved Storm Water Pollution <br /> City State A Tip Prevention Plan or the City of Stockton Storm Water Pollution <br />' <br /> Location of Proposed Work,etc ��L <br /> Prevention Maintenance Staff Guide whichever is applicable <br /> JfZ� P—'� fa.$ �5tkr <br />' K.� <br /> /Contractor Address 1 (� r tri By Date <br /> wne <br /> Estimating Staring Date Completion Date IC- -A—03 Permit Expiration Date �D <br />' I or We) hereby apply for an Encroachment Permit to carry out the following work _ <br /> c i I r y, i a etas ave I L_,a n e- o F L, <br /> er'Z w r IP—r c-- q c. I ar C T 6- Lv C <br /> so I el w ci+ 1" E, <br /> 6 ' Lam.-4.t n opeot e li t,-;a r - ;S. n C y r1 j erl e- <br /> +axe- 4 i 1 z h - I , �z-� <br />' The above named apph=it hereby requests purrnrsswn to Qtr. <br /> j P A.+VA G PERMIT FEE <br /> II Additional Footage Fee $ <br /> Trench Fee $ <br /> Sewer Tap Deposit $ <br /> TOTAL DEPOSIT <br /> e ellz Building Permit No <br />' Improvement Plan No <br /> Supplemental Conditions <br /> I <br /> Show sketch above or ruler to drawing submmsd <br /> IIMPORTANT. Applicant hereby agrees to comply with all provisions of this permit as well as ail applicable City ordinances,resohrtions, <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 /> I 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 cerhficate of insurance shall be submitted to the City Risk Manager prior to issuance <br /> of this perrnit <br /> I SHALL CALL(209)937-8365 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS BUT NOT 1N EXCESS OF 72 HOURS, <br /> PRIOR START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> OERMIT IF WORK DOES NOT BEGIN WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> ECOME.INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER (FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> UBDIVISION 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 /> REAL]GENERAL PROVISIONS ON REVERSE SIDE OF IS M EFORE SIGNING <br /> ISigned Phone — 1 iYJL <br /> 1st-Permittee(white) d4m-nartrnri frmnk) girl Fila rvnlinwl <br />