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Date q-3-0 <br />Permit Expiration Date ZVIS /4 I <br />By <br />READ GENERAL PROVISIONS ON REVERSE SIDE OFT IS PE IT BEFORE SIG <br />Signed: <br />tst-Permittee (white) 2nd-inspection (pink) 3rd-File (yellow) <br />Phone.5/ Z -Nce( xzto <br />4th-Finance (white) <br />C 020 3 <br />CITY OF STOCKTON <br />PUBLIC WORKS DEPARTMENT <br />APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br />Applicant's Name 0-12, M LL <br />(Owner/Contractor) <br />Address I3S- loco <br />City bak IC.1 na State 04 Zip Ciei G, 1 2 <br />Location of Proposed Work, etc. On kiln VACt 1 1.-o,raljt+k Si- <br />4 CALI r\Pi1 1 FI 1 62)if b <br />Owner/ Contractor Address <br />Estimating Starting Date 01- ()p(11 ?DoI Completion Date 01— Aprl, <br />APPROVED: BY THE PUBLIC WORKS DIRECTOR <br />Subject to the General Provisions and Sri ,e01C;onditions, and all <br />work must conform to the project's approved Stol-n Water Pollution <br />Prevention Plan or the City of Stockton Storm Water Pollution <br />Prevention Maintenance Staff Guide, whichever is applicable. <br />Date cA-o) o I <br />Phone <br />I (or We) hereby apply for an Encroachment Permit to carry out the following work: IIISV033, eANICA S0ANT(.9 <br />cnkfl ( 9) C,P7 100/1Y1c7,N CANA UsukIntp-eivi- fr\ LzioL,R0,4c <br />11- Cit11-1(-9)ct lert 4-11cLI (kW N/V LA k U. iv e <br />pc.EAV Vv\e- If CI CA t. \ +Lc 1/\ .0b I k„P\ IcHrt <br /> <br />The above named applicant hereby requests permission to - <br />PERMIT FEE rnS <br /> <br />oc> <br /> <br />Additional Footage Fee <br /> <br />Trench Fee <br />Sewer Tap Deposit <br />TOTAL DEPOSIT I 2F <br /> <br />-er <br /> <br />"Pl SU ()ladled . <br /> <br />Building Permit No. <br />Improvement Plan No. <br />Supplemental Conditions: <br /> <br />Show sketch above or refer to drawing submitted <br />fiMici <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 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 />60369