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Additional Footage Fee <br />Sewer Tap Deposit <br />TOTAL DEPOSIT <br />Building Permit No. <br />Improvement Plan No. <br />Supplemental Conditions: <br />The above named applicant hereby requests permission to : <br />Show sketch above or refer to drawing submitted <br />CITY OF STOCKTON <br />PUBLIC WORKS DEPARTMENT <br />APPLICATION FOR ENCROACHMENT ON PUBLIC RIGHT-OF-WAY <br />70866 <br />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 />Mainten e St ff Guide, whichever is applicable. <br />Applicant's Name 16e..„,:,„,,,to a -0 &V Date k)242-1/0-7 <br />(Owner/Contractor) <br />Address 1317 RoPrO Phone 4(p r7 -I o JZA0 <br />State ç- Zip 95245 <br />RPi GAR.QC-Z. <br />715 AL Hvnier -91-rca c-÷- <br />Owner/Contractor Address 37 5 1-)olt.../ ig0.1 .57-oucrp By 4‘ate 7- <br />Estimated Starting Date OV0 i/ Completion Date 01/ 0 // 0 Permit Ex ration Date 41 4-0 7 <br />I (or We) hereby apply for an Encroachment P,ermit to carry out the following work: <br />9 Iv it) th <br /> <br />City 5 TO< 'I 0/N <br />Location of Proposed Work, etc. <br />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 />PERMIT NOT VALID WITHOUT <br />CONTROL NUMBER. <br />CALL (209) 937-8366 TO REQUEST A CONTROL. <br />NUMBER NO LESS THAN 24 HOURS, BUT NOT <br />EXCESS OF 72 HOURS PRIOR TO START OF WORK. <br />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: <br />„Ski) s'N' <br />Phone: 2-1 L 3)0 r) <br />3rd -File (yellow) 4th -Finance (white) 1st -Permittee (white) 2nd -Inspection (pink)