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S <br /> CITY OF sT6cKTON 67882 <br /> DEPART <br /> PUBLIC WORKS DEPARTMENT <br /> �,��,, ��A/PPLICCATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicants a ( ',/[f tYdl/Nptf Dattec-UW <br /> APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner ontrac�7) <br /> Address7t / 5 �'buSubject to the General Provisions and Special Conditions,and all <br /> Pho = x work must conform to the project's approved Storm Water Pollution <br /> city Skxs..�►-r a 2 State c ZjpPrevention Plan or the City of Stockton Store Water Pollution <br /> P JRI'L ew Prevention Maintenance Staff Guide,whichever is applicable. <br /> Location of Proposed Work,etc. 4i i�i i. <br /> i t�CaM�C O Of r4 <br /> -Gd�Sf �nSii o(r��, r�. � G '� <br /> Owner on a rAddress H37 <br /> SC'Mra� f IfU 6 /' Date 'ler—a <br /> Estimating Starting Date /2 1 �0¢ Completion Date y Permit Expiration Date <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: 011k nz4 <br /> f .! . <br /> Aja i L loin c7yl s et a�2 <br /> The above named applicant heresy re4ueslS permission to- <br /> .,IJ p � � //'�J PERMIT FEE............................$ <br /> �Iea6e //s Lk, / k�,�-�-2rJ Additional Footage Fee............ $ <br /> /�LC �L� !-U' Trench Fee............................... $ - <br /> G'l�lJ Sewer Tap Deposit....................$ <br /> J TOTAL DEPOSIT.........$ <br /> Building Permit No. <br /> Improvement Plan No. <br /> Supplemental Conditions: <br /> Aet y 0116vel <br /> rge <br /> SQQ /� N c4 Vii' <br /> Show sketch above or refer to drewing submitted v5 <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 indemnify 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 SIQE OF THIS PERMIT BEFORE SIGNING. <br /> Signed )< Phone:f 7%W 1U <br /> list-Permittee(while) 2nd-Inspection(pink) 3rd-File(yellow) 4th-Rnance(white) <br />