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• CITY OF STOCKTON . 70232 <br /> PUBLIC WORKS DEPARTMENT <br /> M& APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> MM 75 0 1 <br /> t 1`nvito�ME� <br /> Applicant's Name AdVRfuCEA GFo Date 41ZT APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) <br /> Subject to the General Provisions and Special Conditions, <br /> Address 1537 .5(9A W RnAn Phone <br /> and all work must conform to the project's approved Storm <br /> City 5 TOCK Tw✓ State C_Zip 9 SZ IS 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. (d than WAY MA/KPainten c Staff Guide,whiche i <br /> lQ2� s applicable. <br /> / <br /> Owner/Contractor Address By � Date`�'—� <br /> Estimated Starting Date7 1 Completion Date 7 25 V Permit Expiration Date <br /> Cy 11 <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: �Oy SOS bpt;..Y,% IA4rrH <br /> f- WlOn W t ee t` �1VO.Suni, IV <br /> ATTENTION: Applicant/Contractor—you are responsible to 7O <br /> replace all broken, damaged, and/or raised sidewalk, curb and PERMIT FEE........................... $ <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.................. $ z <br /> TOTAL DEPOSIT ...... $ / �© <br /> S ` Building Permit No. <br /> (� Improvement Plan No. <br /> Supplemental Conditions: <br /> Walk 5rko 6<- <br /> W o RSC �( �/ 11 ao A- d— TOPIn <br /> 0INTl R_ NU SER. <br /> CALL ('209) 9374-M6 TO REQUEST A CONTROL <br /> NUMBER 40o LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF72 HOURS PRIOR TO START Of WORI<. <br /> Show sketch above or refer to drawing submitted <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. _1L <br /> Signed: J - QNJ"P Phone: 2log %7/00tii0 <br /> 1st-Pprmittea (white) 21d -Inspection (pink) 31d-File(yellow) 4'h -Finance (white) <br />