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CITY OF STOCKTON <br /> PUBLIC WORKS DEPARTMENT 72226 <br /> APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br /> Applicant's Name dt�'c'•Y� � �g2v+1 Date APPROVED: BY THE PUBLIC WORKS DIRECTOR <br /> (Owner/Contractor) 2-55 <br /> Address S5 l�n�i8v'3i�u, 117V4P Phone�Il --t 3a�-�353 Subject to the General Provisions and Special Conditions, <br /> i--r— and all work must conform to the project's approved Storm <br /> City S�✓pM Mytttu State cA Zip 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. -�V f,w- 5Q.124"- Mainten ce Staff Guide, whichever is applicable. <br /> (.fin r'✓�.✓5, Z S S- B4,6 Date <br /> Owner/Contractor Address C.SS" /l.c Y <br /> Estimated Starting Date vj"= 1 ,?,-so v Completion Date 4:tg, 1. -aC-9 Permit Expiration Date Fy-6 <br /> I (or We) hereby apply for an Encroachment Permit to carry out the following work: <br /> See, t.on,r� I/l� ", pct ny^_t{n Vt <br /> I s "CV/-L- 1S �JLe_:I=I <br /> C ele- <br /> � P i <br /> ClPiryt i r S�yt D th c.z l`f $— <br /> ATTENTION: Applicant/Contractor-you are responsible toy# G1© <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.................. $ ' <br /> TOTAL DEPOSIT ...... $ <br /> ,f� Building Permit No. <br /> �;e s- Ll �/ LVA✓� Improvement Plan No. <br /> Wk-4.1 6141t� y , Supplemental Conditions: <br /> PERMIT NOT VALID WITHOUT A <br /> CONTROL NUMBER, <br /> CALL (209) 07-&W TO REQUEST A CONTROL <br /> NUMBER NO LESS THAN 24 HOURS, BUT NOT IN <br /> EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br /> Show sketch above or refer to drawing submitted CONTROL# <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 /> Signed: cX 4, �� Phone: 17►,- L S3 <br /> 1St-Permittee (white) 2nd-Inspection (pink) 3rd-File (yellow) 41h -Finance (white) <br />