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I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br />1-rr. .4".. ; e p, 74,1 <br /> xi,- ,-)(` Y V. c 1,4• <br />/.)(,/ / , (./6- d(i; <br />TL <br />e ebq 0 :e <br />r•-• <br />( L <br />YI')•,•./". .//j <br />r .4 <br />PERMIT FEE <br />Additional Footage Fee <br />Sewer Tap Deposit <br />TOTAL DEPOSIT <br />Building Permit No. <br />Improvement Plan No. <br />Supplemental Conditions: <br />ERMIT NOT VAUD WITHOUT A <br />ONTROL NUMBER. <br />CALL (209) 937-8386 TO REQUEST A CONTROL <br />NUMBER NO LESS THAN 24 HOURS, BUT NOT II <br />EXCESS OF 72 HOURS PRIOR TO START OF WORK <br />CONTRoi <br />ATTENTION: ATTENTION: Applicant/Contractor — you are responsible to <br />replace all broken, damaged, and/or raised sidewalk, curb and <br />gutter from score mark to score mark adjacent to the parcel; <br />remove USA markings upon completion of the permitted work. <br />The above named applicant hereby requests permission to : <br />„ <br />Iff V4-02. <br />Show sketch above or refer to drawing submitted <br />State (/'`.1 Zip c.Fr P/C <br />Location of Proposed Work, etc. <br /> <br />)4. <br />r:f/C 07r /11/, Af/en <br />City <br />CITY OF STOCKTON <br />PUBLIC WORKS DEPARTMENT <br />APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br />747 <br />Date C/'/ii APPROVED: BY THE PUBLIC WORKS DIRECTOR <br />Subject to the General Provisions and Special Conditions, <br />and all work must conform to the project's approved Storm <br />Water Pollution Prevention Plan or the most current version <br />of the City of Stockton Storm Water Pollution Prevention <br />Maintenance Staff Guide, whichever is applicable. <br />Owner/Contractor Address By <br />Estimated Starting Date K/,-. ;-"/ Completion Date <br /> <br />Date <br /> <br />Permit Expiration Date <br /> <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) 937-8391. <br />READ GENERAL PROVISIONS ON THE REVERSE SIDE OF THIS PERMIT BEFORE SIGNING, <br />Signed: .%;.;<( Phone: <br />9nd _Incnprtion (nink) 3rd -File (yellow) 4rn -Finance (white) <br />Applicant's Name cc <br />(Owner/Contractor) <br />Address 7 3 C. Sp.';-;e71 Phone ./...7/