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, f"..,,>,�.riz,ina F �':1�:331.&"'rte'.�R+�Hii3...G+OG.e�. ! 1" •,,,/ d �I <br /> 1 <br /> aNr,t knit��2f�..,ltii'+krou✓M� eea <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name bate qlllkfs APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/ tra r) <br /> Address sh(.YJ koa Phone 467-/pow Subject to the General Provisions and Special Conditions, <br /> and all work must conform to the project's approved Storm <br /> City -9-0(k1-0A State Zip 9S2/9_ Water Pollution Prevention Plan or the most current version <br /> of the City of Stockton Storm Water Pollution Prevention <br /> Location of Proposed Work, etc. r,✓ %L.164 40 Maintenance Staff Guide,whichever is applicable. <br /> 8pb6/or�o�S,I L, kcuu L 7� /�# /1moo�— wcs - - ! r <br /> Owner/ ontra or Address _,, . CA- ByDate <br /> Estimated Starting Date*4_0_1 Completion Date 2 Permit Expiration Date <br /> (or We) hereby apply for an Encroachment Permit to carry out the following work: ILf0+'Lf'+ C,P C -3 SCJ G / °i�� <br /> Cel r eA-4 8 on S <br /> O d f'I e i� <br /> y- r IOCtt n <br /> ATTENTION:ApplicanVContractor-you are responsible to n. <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ c-v <br /> gutter from score mark to score mark adjacent to the parcel; <br /> remove USA markings upon completion of the permitted work. Additional Footage Fee .......... $ <br /> The above named applicant hereby requests permission to: �— <br /> Sewer Tap Deposit.................. $ <br /> pleo " re, <br /> 4, <br /> 10 . ,f n TOTAL DEPOSIT ...... $ G �� <br /> �*eq f wvr, flan) `ate d Building Permit No. <br /> pl^�L(f y / - Improvement Plan No. <br /> Supple�Conditions: <br /> PERMIT NOT VAUD WITHOUT A <br /> CONTROL NUMBER. <br /> CALL (209) 937-M TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WOR <br /> ( CEK. <br /> Show sketch above or refer to drawing submitted `e` N••`OL# <br /> IMPORTANT: Applicant hereby agrees to comply with all provisions of this permit, as well as all applicable city ordinances, resolutions, <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 <br /> does not meet the above requirements. Failure to comply will be cause for revocation of this permit.Applicant agrees to indemnify and hold <br /> the City harmless against any and all losses, costs, or damages resulting from injury to persons, death of person or damage to property <br /> 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 <br /> Manager prior to issuance of this permit. <br /> IF THE WORK DOES NOT COMMENCE 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 SPECIFIC <br /> INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.)PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE <br /> SIDE OF THIS PERMIT,PERMITTEE SHALL CALL(209)937-8381. <br /> READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING. �" <br /> Signe d )c�1/ Phone: (% -/d <br /> I" -Permittee (white) 2nd-Inspection (pink) 3rd-File (yellow) 4m-Finance(white) <br />