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FRAM :SECOR FAX NO. :2099399045 <br /> . �9. 27 2007 08:33RM P1 <br /> CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT 72 6 4 6 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> 5-T - <br /> rApplicants Name %A( Date <br /> (OWher/Contractor) Old O0 APPROVED:BY THE PUBLIC WORKS DIRECTOR <br /> (Own <br /> Address-7o I �yvre 91Phone q'i/s-S'6 i•V%Ob Subject to the General Provisions and Special conditions, <br /> City_ . ., r. rAa„ State zi and all work must conform to the project's approved Storm <br /> 1 P�_SZ'�-y Water Pollution Prevention Plan or the most current version <br /> Location of Proposed Work,etc. {^/, f.�/2pe� /�U�� of the City of Stockton Storm Water Pollution Prevention <br /> s-+,t--•--T Mainten a Staff Guide,whichever Is applicable. <br /> CMrner/Contractor Address _ B <br /> y <br /> Estimated Starting Date_ Zd/b$' Completion Date 9�/._ 5.106 Permit Expiration Dateate <br /> I(or We)hereby apply for an Encroachment Permit to carry out the following work. _M •�:'�W.M t-Jc I 'r,e,L rr-1` <br /> �tP Tey;;,ItA� <br /> ATTENTION:Applicant/Contractor—you are responsible to <br /> replace all broken,damaged, and or raised sidewalk, curb andr O'+ <br /> gutter from score mark to score mark adjacent to the parcel; PERMIT FEE........................... $ - <br /> remove USA markings upon completion Of the Permitted work. <br /> Additional Footage Fee....._.... $ <br /> Tne above G applicant nareey r�eg�gbela�permimon toSewer Tap Deposit.................. $ <br /> TOTAL DEPOSIT ...... $ <br /> y <br /> Building Permit No. r7 �nO <br /> Improvement Plan No. 2J <br /> Supplemental Conditions: (S�Q <br /> PERMIT NOT VALID WITHOUT A <br /> CONTROL NUMBER, <br /> CALL (209) 937.8386 TO REQUEST A CONTROL <br /> NUEa9ER NO LESS THM 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> CONT€tOU SS 0 4�2L0U <br /> Show akalcb above or refer to drawing tubmiltcd <br /> icant <br /> rees <br /> th <br /> ll provisions <br /> Standards and Specifications eu erttly in effect,comply d'oapay o the Cityfirsta f actual cost forelemovall andllprope replor <br /> aement finances, any litem which <br /> does not meet the above requirements. Failure to comply will be cause for revocation of this Perla.Applicant agrees to t o <br /> Ile <br /> City harmless against any and all losses,costs,or damages resulting from injury to�rsons,death of person or damage to property <br /> occuning at the site of,or as a result of,work to be performed under this g emhify and hold <br /> Manager prior to issuance of this permit. Permit.A Cert'trate of insurance Shall be submitted to the City Risk <br /> IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OFA CONTROL NUMBER,THE CONTROL NUMBER WILL <br /> SUBDIVISION BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR <br /> WILL <br /> INSTRUCTIONS PRIOR TIO THE BEGINNING OF ANY WORK.) RIOR TO ANY REQUIRED N SHALL CONTACT THE ASSIGNED CrN PROJEOR <br /> ENGINEER <br /> AT(209) <br /> 937-8411 <br /> ON THE REVERSE <br /> SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(tog)937-SSBI, <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. <br /> t ` <br /> Signed _ Phone: 14-71r2^7//Y <br />