Laserfiche WebLink
ij <br /> CITY OF STOCKTON 6 882 <br /> PUBLIC WORKS DEPARTMENT <br /> 1APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicants a Aur'.2[VIJFn t1Y0)rizt /Date� /¢ _ APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (OwnerlzzziL ontrar <br /> �-tl/ <br /> �.er Subject to the General Provisions and Special Conditions,and all <br /> Address 37 Si•><;t.t.r.7leri� Phone�I[b7-IiOG, work must conform to the projects approved Storm Water Pollution <br /> City Sylc 1( E-ra.) State 9- Lp q�dj S Prevention Plan or the City of Stockton Storm Water Pollution <br /> Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc. S/tI L-��s/r'c/L e,0i .S L2yr i5 C)A:, . <br /> kM {7LNu�E )2ZY<6r itdtSf �5i�,�v(� ��'1� Sp WILL. <br /> Owner o a rAddress 7j7 S�tr� It�rs,c�Jf .�J'�L-C K-�rr�%J B Data <br /> Estimating Staining Date 'e Y�t7TCompletion Date 4 ?� y Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work:--/t?4— G/ OlttZ ✓ z-"2 <br /> vm <br /> ��i „uta cod 1^crza� E 921 -.5, <br /> L� lsc>� Wa se � t7t22 <br /> V00 <br /> The above named applicant hereby reouests permission to- <br /> �+ PERMIT FEE............................$ <br /> AL?6e � /� � � /j l� Additional Footage Fee............ $ <br /> t f �rti�.c, Trench Fee............................... $ <br /> G"W!�(- C�- ` / ✓i�I���a , .Sewer Tap Deposit....................$ '�- <br /> // TOTAL DEPOSIT.........$ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> rorty 'lw <br /> ege <br /> SQA)r/e` y r�®w� �r Z, s w[4 <br /> Slow sketch above or War to drawing submitted //fir V/� /-�^ kti' �� <br /> r <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 does <br /> not meet the above requirements. Failure to comply will be cause for revocation of permit.Applicant agrees to indemnity and hold the City <br /> 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 certificate of insurance shall be submitted to the City Risk Manager prior to issuance <br /> of this permit <br /> PERMITTEE SHALL CALL(209)937-8366 FOR A CONTROL NUMBER NO LESS THAN 24 HOURS,BUT NOT IN EXCESS OF 72 HOURS, <br /> PRIOR TO THE START OF WORK,AND PRIOR TO ANY REQUIRED INSPECTIONS,AS IDENTIFIED ON THE REVERSE SIDE OF THIS <br /> PERMIT.IF WORK DOES NOT BEGIN 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 <br /> SPECIFIC INSTRUCTIONS PRIOR TO THE BEGINNING OF ANY WORK.) <br /> READ GENERAL PROVISIONS ON REVERSE SI E OF THIS PERMIT BEFORE SIGNING. / <br /> Slgn' Phone: s//7 Its'may.. <br /> 1st-Permittee(white) 2nd-Inspection(pink) 3rd-File(yellow) 4th-Finance(white) <br />