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CITY OF STOCKTON *.ale PUBLIC WORKS DEPARTMENT 7 1 7 3 4 4PPIVa 1C TJON FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY ''Llel �Eff Applicant's Name 6_10 Date APPROVED: BY THE PUBLIC WORKS DIRECTOR (Owner/Contractor 'S [i,r / Address�_ttLL-- Phone '47470,6 Subject to the General Provisions and Special Conditions, _ and all work must conform to the project's approved Storm City S` ?rx7RZ+it✓ State IA Zip Water Pollution Prevention Plan or the most current version ',J �. ,L of the City of Stockton Storm Water Pollution Prevention Location of Proposed Work, etc. lq,//T�l i n% Com'{ ST�Ga Mainte ce Staff Guide, whiche er is applicable. S//7ttL�c/� On/ S Alfie CAJ1 VAfV le E. ",�Ila R Owner/Contractor Address By � 7- — / "O$ Estimated Starting Date Z 3--fi�5 Completion Date Permit Expiration Date / C/ "' %—d I (or We) hereby apply for an Encroachment Permit to carry out the following work: A 64/�ew)y 6,4 -4— ao ljd r/r SSSZ-1_-1(,164_y _Yi- C�il 1"' � 7% le Sirck&A) r //eCA-19 ti 4 -s:,, SQ; -14Kli 7 �V)Uni�vri��/ GUGI[ �1Flr e fE7//c71�litzr keeir--/iu ) : a LE(c I, S. 6y//SOry 6,s ee� e- *T,4 C 1 Wale7- /) y ATTENTION:Applicant/Contractor—you are responsible to S3 q replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ gutter from score mark to score mark adjacent to the parcel; remove USA markings upon completion of the permitted work. Additional Footage Fee .......... $ The above named applicant hereby requests permission to Si'f-� Maty Sewer Tap Deposit.................. $ Sic a'flrc c. _7 �r 00 TOTAL DEPOSIT ...... $ / fel � 05-X91 i ermit No. W Improvement Plan No. Supplemental Conditions: PERMIT NOT VAUD WTHOUT A CONTROL NUMBER. CALL (209) 937$366 TO REQUEST A CONTROL NUMBER NO LESS THAN 24 HOURS, BUT NOT EXCESS OF 72 HOURS PRIOR TO START OF WORk Show sketch above or refer to drawing submitted CONTRO —^^^---•—•---^�--^•---•-•^--- - IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit, as well as all applicable city ordinances, resolutions, 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 not meet the above requirements. Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnify and hold the City 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 of, or as a result of, work to be performed under this permit.A certificate of insurance shall be submitted to the City Risk Manager prior to issuance of this permit. IF THE WORK DOES NOT COMMENCE WITHIN 72 HOURS OF THE ISSUANCE OF A CONTROL NUMBER,THE CONTROL NUMBER WILL BECOME INVALID AND THE PERMITTEE SHALL CALL FOR A NEW CONTROL NUMBER.(FOR CAPITAL IMPROVEMENT PROJECTS OR SUBDIVISION IMPROVEMENTS,PERMITTEE SHALL CONTACT THE ASSIGNED CITY PROJECT ENGINEER AT(209)937.8411 FOR SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937-8381. READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. F {/ Signed: i / ' V Phone: Y/W /0 i v 1St-Permittee (white) 2nd-Inspection (pink) 3f0-File (yellow) 41h-Finance (white)