HomeMy WebLinkAboutN2018-0261r I' ''•,
n �
City of Newport Beach
Civicenter DNewport Beach, CA 92660
Permit Counter Phone (949)44-3311
Online Inspection Request - ww w.newportbeachca.gov / Online
$eNICeS
lpil III �III IIII
��1111111111111111111111111111111
11 Permit No: N2018-02610 .
Project No : 0252-2017 SCANNED
U
Inspection Requests Phone (949)644-3255
Job Address:
3804 SANDUNE LN NB
Thomas:Guide: 919G2
Description :
NEW DRIVEWAY APPROACH PER STD 162-L, NEW CURB
AND GUTTER PER STD, REMOVE CONCRETE STRIPS IN PARKWAY.
Parcel #:
4580-610-5 -
Legal Desc :
N TR 6425 LOT 65
Owner:
REDDY NAVEEN S
Contractor : TERRA PRIMA INC
Phone:
Phone: 714-679-2002
Address :
3804 SANDUNE LN
r rI
Address : 3800 TOPSIDE LANE
CORONA DEL MAR, CA 92625
PIS
CORONA DEL MAR CA 92625
Contractor State Lic: 982237
Applicant:
TERRA PRIMA INC
License Expire : 03 31, 2019
Phone:
714-679-2002 [
Address :
3800 TOPSIDE LANE
CORONA DEL MAR CA 92625
Business License : BT30045426
Business Expire : 11 30, 2018
Special Cond.:
PRE -CONSTRUCTION MEETING REQUIRED
Workers' Compensation Insurance - -
Carrier : SOUTHERN INS CO
Policy No : OWC1007290
W. C. Expire : 03 01, 2019
Permit Processing Fee :
$241.00
Sewer Connection : $0.00
Total Fee $571.00
Agreement Fee :
$0.00
4TT Box Cover: $0.00
Paid : $571.00
Traffic control Plan Check :
$0.00
Total Water Meters : $0.00
Balance : $0.00
Inspection Fee :
$330.00
Water Meter Connection : $0.00
Receipt No:
Refundable Deposit:
$0.00
Total Water Meter Box : $0.00
Street Tree Fee :
$0.00
Adjustment : $0.00
Processed By :
Date : _/_/
Other Department : Date
Utilities Approval :
Traffic Approval :
Date : _/_/
Date : _/_/
Permit Denied Date
Issued Permit : Date /�//7/�,O/
General Services Approval : Date : _/_/
5/30 //�
FEE WORKSHEET FOR ENCROACHMENT PERMIT,
CITY OF NEWPORT BEACH
PUBLIC WORKS•DEPARTMENT -
All Fees Are Non -Refundable Unless Otherwise Stated
PROJECT ADDRESS: PERMIT
C N2018- D �I
J (-(4•L_ NUMBER:
APPLICANT: —TOMMUPMED BY FIUE1L1GWORKS DEPARTMENT
Permit Processing Fee:
Public Works Only
Other Department
Agreement Fee:
Preparation of Report/Agreement
Document Recordation Fee
Monitoring Wells
Street/Alley/Walk Closure:
Traffic Control Plan Check
QQ Inspection Fee:
$241.00Public Works Field Inspection
$275.00 Utilities Field Inspection
General Services Inspection
Water Quality/Artificial Turf Inspection
$.00
$192192.00 Refundable Deposit:
$502.00 Improvements
$65.000 Newspaper Rack Inspection
$165.00
$121.00
$165.00
$108.00
TBD
TBD
$108.00
8-1/2" x 11" $65.00= Sewer Connection Fee $250.00
24" x 36" $143.001 1 4TT Box & Cover $64.00
Additional_ ___________'
THE FOLLOWINQ IITEMS REQUIRE APPROVAL FROM THE ,Revenue Division I
QtY•
,�
(Water Meter:
Installation Charge
$528.00
13/4" Meter $50.25
1
11" Meter $121.50
Water Meter Boxes:
11 1/2" Meter $285.00
1" DFW Meter Box
$96.66 I
11 1/2" Turbine Meter $700.00
12" Meter $425.00
12" Turbine Meter $845.00
13" Meter $3,310.00
2" DFW Meter Box
F::::]
$203.24 1
1
1
1
14" Meter $4,730.00
6" Meter $7,190.00
MISCELLANEOUS
FEES
city.
Budget Number
Certificate of Compliance Fee (+100% of hrly over 3 hrs)
$288.00
5200-5029
Development Services Fee (Plan check hourly)
$155.00
5200-5015
Final Tract Map Checking Fee
$2,488.00
5200-5026
Final Parcel Map Checking Fee - Moderate
$2,488.00
5200-5027
Lot Line Adjustment Fee
$1,079.00
5200-5028
Park Dedication Fee Zone
_ TBD
405-470_
Street EasemenWacationFee (+100%ofhrlyover 4hrs)
$1,022.00
5200-5031
Street Tree Fee ($700 Planting Fee)
TBD
030-2284
Engineering Tech:
Total Amount Due:
For Finance use only
r O�
Permit ecialist
Receipt No.
f:/uwWpo lsharea/wv aWmastersrep hont ana back masters/
Rev. 12/18/2017
apfaeaneet ais+avi a 1118117
w
ALL UNDERGROUND WORK"SHALL BE PERFORMED BY A'LICENSED-.CONTRACTOR "•
Contact "Underground Service'Alert" A$Least 48-Hours.in Advance
of Any,EXcavation at1800-422-41334
TERMS AND CONDITIONS OF ENCROACHMENT PERMIT
WORKER'S COMPENSATION INSURANCE (Section 3800 Labor Code)
1.
Encroachment Permils may be taken out by the owner of benefited properly or a licensed contractor. A licensed
I certify that I have a Certificate of consent to self -insure, Certificate of Worker's
contractor must provide a `Letter of Authorization" to allow another party to pull a permit. An approved copy of the
Compe all I surance, or it Certified Cc{p�y lh of.
permit and construction plan shall be kept at the job site at all times. Work, which has been done prior to issuance of
a permit, is subject to rejection/fine. City reserves the right to void permit if work does not commence within 30 days
Date Signature .GCL
after date of issuance.
CERTIFICATE OF EXEMPTION (Section 3800 Labor Code)
2. The Permittee agrees to defend, indenmify and hold the City, its authorized agent, officers, representatives and
employees harmless from any responsibility, liability, suit or action of any description arising out of any accident, loss
I certify that in the performance of the work under this permit, I shall not employ
or damage to persons or property occurring as a result of work undertaken under this permit.
any person so as to become subject to California Worker's Compensation Laws. If,
3.
All work shall be done in accordance with the approved plans, Standard Special Provisions and Standard Drawings
after signing this certificate I become subject to the Worker's Compensation
of the City of Newport Beach, and in compliance with all applicable State laws and City ordinances.
provisions of the State Labor Code, I must comply with the provisions of Section
4.
Pernince guarantees all work pedonned under this permit to be free of hidden and latent defects. Any failures shall
3700 or this permit shall be deemed revoked.
be corrected within two weeks after notification to the satisfaction of the Public Works Director.
5.
A valid State licensed contractor amst perform all construction within the public right-of-way, unless waived by Ore
Date: Signature:
Public Works Director.. A valid State Contractor License Class A can perform any work in the public right-of-way. For
construction or connection to water lines a valid Stale Contractor License Class C-34 is required. For construction or
CONTRACTOR LICENSE EXEMPTION
connection to sewer lines a valid Slate Contractor License Class C-42 is required.
6.
All trenching and/or resurfacing shall conform to City Standard 105-L for parkway/roadway and City Standard 140-L,
As the Owner of the benefiting property, I certify I am personally performing all
in the alley, where a nlininmm half -alley width resurfacing shall be provided, unless otherwise directed by the Public
work in the Public Right -of -Way.
Works Dept. Contractors shall obtain permits to perform excavation or trench work from the California Division of
Date: Signature:
Industrial Safety prior to commencing underground construction as required by State law. Walls and faces of all
excavations over 5 feet in depth shall be protected by a shoring system, sloping of the ground, or other equivalent
means. Trenches less than 5 feet in depth shall be guarded whenhazardousground movement may be expected.
HOLD HARMLESS STATEMENT
7.
The Public Works Department Inspectors must inspect all work in the Public right-of-way. Forms and subgrade must
I understand that I am locating minor encroachments within the City Right -of -
be inspected and approved before concrete is ordered/poured. Sewer, pipelines, and subgrade construction must be
Way/Easement. As property owner it is my responsibility to maintain the
inspected and approved before backfilling, or applicant may be required to excavate site. Separate Utilities
encroachments. I will be responsible for replacing the improvements if the City
Department or General Services Department inspections may be required depending on scope of work performed
removes them for maintenance of utilities or other public need. I shall indemnify
A.
All trench restoration must be inspected by the Public Works Department, No utility installations) shall be allowed
and hold the City harmless for any liability associated with the minor
over or within 5 feet of any City utilities, unless approved by the Public Works Department. Locate and pothole
encroachments.
existing City -owned utilities fie: water, sewer, or street lighting conduits) to verify locations. Maintain a one -foot
clearance over or under existing City -owned utilities. Sewer cleanouts require VCP or PVC SDR35 be used with a
Dale: Signature:
4TT box over the riser.
44-hour notice for Encroachment Permit Inspection is required by calling
9. Properly lighted barricades must be provided and maintained around all trenches, excavations and obstructions. All
"Manual
signs, flags, lights and other warning and safety devices shall conform to the requirements of the current of
Warning Signs, Sights and Other Devices for the Use in Performance of Work Upon Highways", issued by the
Public Works at 949.644-331
California Department of Transportation. If needed,barricades can be obtained from the City at a charge of $10.00
15. Any above ground utility fa sties wit equire tlocunlenled approval from the adjacent
per barricade per day, with a minimum charge of 535.00. It is the responsibility of the applicant to place barricades to
protect the general public. Access to fire hydrants must be maintained at all limes.
affected property owner(s).
10.
Work within or near beach sensitive areas will not be allowed during, City holidays, spring break, Memorial Day
16. Homeowner, contractors, and subcontracotrs may each be liable for violations of /Vater
weekend, su niner between June 15 and September 15, and during the holiday season from December 19 to
Quality Laws. Best Management Practices will be enforced, It is against the law to
11.
January 1, unless approved by the Public Works Department.
Any work that extends into traffic or parking lanes and impedes the normal flow of traffic requires the applicant to
discharge construction debris into the gutter and storm drain, Felony violations of Water
acquire a Temporary Street Closure Permsl from the Public Works Department Access for fire, police and
Quality Laws are punishable by fines up to $25 , 000 and/or up to three years in State
emergency vehicles thus( be maintained at all times. Traffic Control must be per Work Area Traffic Control
prison plus the full cost to clean up an illegal discharge or spill.
17 . If a refundable deposit was paid, applicant roust submit a Soils Compaction
Handbook (WATCH). No nighttime traffic lane closures. unless prior approval has been granted. Any lane(s) closure
Certificate or Evidence of a Slurried Backfill and request a final inspection from the
on a major street will only be allowed belween 9:00 a.m. and 3:00 p.m. (Monday thru Friday), unless approved by
the Public Works Department. Any work affecting the Stale Highway's traffic or within the State Highway right-of-way
Public Works Department. Monies may be held for six months after final inspection
will require a Caltrans Permit. All vehicles shall be lawfully parked
before a refund will be processed.
12.
This permit does not authorize the closure of sidewalks, streets, or alleys for construction access, storage of
18. No trees in the public right-of-way shall be planted, removed, trimmed, or relocated
materials, or parking of construction vehicles unless detailed on an attached Temporary Street Closure
without approval from the General Services Department,
13.
Applicant must notify USA at 1-800-227-2600 2 days before starting any underground construction. Applicant
19. All work in the public right-of-way roust meet the approval of the Public Works
must notify all affected residents 24 hours in advance of restricted access and any inconveniences.
Department or corrections will be required (i.e. removals, exposing connections.
14.
Refuse or unused materials shall be removed within 24 hours after completion of the work. If not removed, the City
etc.). Additional inspection fees may be required.
nlay remove and bill the applicant. Coordinate alley closures with City refuse pick-up days by calling 949-644-3066
20. Permit is for standard materials in the public right-of-way only, unless previously
for the collection schedule so service is not interrupted. To place a dunlpsler or materials in the public right-of-way, a
approved by Public Works and an Encroachment Agreement has been processed.
Temporary Street Closure Permit must be obtained Irons the Public Works Department.
21. Permit is valid for 'description' of work noted on front only. Additional work
performed may require issuance of a separate permit and/or additional fees.
and
work related to this encroachment permit shall be performed until the Public Works Department has Issued this permit. 'Applicant hereby )pknowledges he/she has.read and understands the terms "
'.
conditions of this permand heNo
it lsheagrees to abide by them. Permit Is void if work is not commenced wrtnin;30 days after Issuance.:
Dat xy�J/'F-/� Signature..'`X!'/�//_/_
Permitfees re. nonrefundable..�. �e!
a n
(N) 15' TRENCH DRAIN
N THE EXIST. SEWER
,RD STD-406-L
R IN THE PUBLIC
:D BY A C-42 LICENSED
IR AN 'A' LICENSED
2MIT IS REQUIRED FOR
UBLIC RIGHT-OF-WAY.
3 SHALL COMPLY WITH
JNDING THE SITE IS
,NEW CONCRETE
FEET PAVEMENT
THE TIME OF
TION AND THE EXTENT
\DE AT THE
SINSPECTOR.
SANDUNE
NEW CONCRETE
DRIVEWAY APPROACH -
(N) 2-CAR APPROACH -
INSTALL PER CITY STANDARDS
STD 160-L, STD 162-L
EROSION AND SILTATION CONTROL NOTE:
PROVIDE SANDBAGS AT ENTRANCE TO DRIVEWAY PER SITE PLAN, SHT. Al
FOR EROSIONCONTROL AND SILTATION CONTROL FOR EXCAVATION WORK
PERFORMED BETWEEN OCT. 31 AND MAY 1. ALL REMOVABLE PROTECTION
DEVISES SHALL BE IN PLACE AT THE END OF EACH WORKING DAY.
(EX. SPA EQUIP.
(EX. 6' WOOD FENCE)
- ROOF LINE
-BLDG. LINE
(EX. A/C)
6' WOOD FENCE)
(N) 15' TRENCH DRAIN
(N) BOTTOMLESS TRENCH DRAIN
W/ DRAIN GRATE
.)CURB CORE
NOR(N
D
POOLS, SPAS, WALLS, FENCES, PATIO COVERS, AND
OTHER FREE-STANDING STRUCTURES REQUIRE
SEPARATE REVIEWS AND PERMITS.
78. _MISCELLANEOUS:
79. PROVIDE SELF -CLOSING DEVICE ON 20-MIN. FIRE -RATED (OR MIN. 1 3/8" THICI
BO. POOLS. SPAS, WALLS, FENCES. PATIO COVERS, AND OTHER FREESTANDING:
81. VERIFY ON SITE QUANTIFY AND DIRECTION OF NEW WOOD FLOORING NEEDE
B2. PROVIDE PAINT AND STAIN SAMPLES FOR OWNER'S APPROVAL PRIOR TO API
83. BUILDER SHALL PROVIDE OCCUPANT A LIST OF HEATING. COOLING, WATER 1
EFFICIENTLY.
84. SMOKE DETECTORS TO BE AUDIBLE FROM ALL SLEEPING AREAS. INSTALL 11
STORY. USE HARD -WIRED, INTERCONNECTED SMOKE DETECTORS IN NEW CC
85. CARBON MONOXIDE ALARMS SHALL BE INSTALLED OUTSIDE OF EACH SLEET
INCLUDING BASEMENTS (R315.3). CARBON MONOXIDE ALARMS SHALL BE HA
R315.1.1 8 R315.1.2.
86. THE CLOTHES DRYER VENT SHALL NOT EXCEED 14-17EET IN OVERALL LENGT
87. FACTORY -BUILT FIREPLACES, CHIMNEYS, AND ALL OTHER COMPONENTS SH/
R1004A
88. ELECTRICAL SERVICE TO BE UNDERGROUND FOR NEW CONSTRUCTION OR
89. EDISON COMPANY APPROVAL IS REQUIRED FOR METER LOCATION PRIOR TO
90. FIELD INSPECTORS TO REVIEW AND APPROVE UNDERGROUND SERVICE REC
91. EROSION:
92. EROSION CONTROL DEVICES SHALL BE AVAILABLE ON SITE BETWEEN OCTO
93. BETWEEN OCTOBER 15 AND MAY 15, EROSION CONTROL MEASURES SHALL 1
DURING THE REMAINDER OF THE YEAR. THEY SHALL BE IN PLACE AT THE EN
94. SEE GRADING AND DRAINAGE PLAN.
95. SEWER:
96. EXISTING SEWER LATERAL TO BE CHANGED AND A NEW CLEAN -OUT INSTALI
97. STAIRWAY:
98. STAIRWAYS AND LANDINGS: MAXIMUM 7 314" RISE; MINIMUM 10" RUN. 6'- 8" 1
99. PROVIDE HANDRAIL FOR STAIRWAYS WITH 4 OR MORE RISERS. (CBC 1009.10.
100. HANDRAILS SHALL TERMINATE INTO A POST OR VOLUTE OR RETURN TO A W.
101. HANDRAILS OR STAIRWAY GUARDS: 34" TO 38" ABOVE THE NOSING OF TREI
FROM 4" TO 6 114", WITH MAX CROSS-SECTION OF 2 114" (FOR ALTERNATE SH
FURTHER THAN 4 1/2".
102. GUARDRAILS SHALL BE PROVIDED WHERE DROP-OFFS ARE 30" OR MORE. (11
SPHERE 4" IN DIAMETER CAN NOT PASS THROUGH.
103. CONSTRUCT GUARDRAILS PER IBC 1013. TOP RAIL OF GUARDRAIL OR HAND':
TOP.
104. STAIR TREADS TO BE OF UNIFORM SIZE AND SHAPE. MAXIMUM TOLERANCE I
MORE THAN 1.25 INCH SHALL BE PROVIDED ON STAIRWAYS WHERE TREAD D
105. _CAL GREEN NOTES:_
106. 2016 CALIFORNIA GREEN BUILDING STANDARDS CODE (CG) IS APPLICABLE T
3 STORIES HIGH). (CG SECTION 101.3.1).
107. ENERGY EFFICIENCY
108. EACH APPLIANCE PROVIDED BY THE BUILDER TO BE ENERGY STAR IF AVAIL
109. -WATER EFFICIENCY AND CONSERVATION-
110. (EFFECTIVE DATE: 7/1/2016); INDOOR WATER USE SHALL BE REDUCED BY AT
(CG SECTION 4.303.1):
111. -TABLE 4.303.2-
112. FIXTURE TYPE I MAXIMUM FLOW RATE TO ACHIEVE 20% REDUCTION
113. SHOWERHEADS -> 2 gpm @ 80 psi
114. LAVATORY FAUCETS -> 1.5 GPM @ 60 PSI
115. KITCHEN FAUCETS ->1.8 GPM @ 60 PSI
1% WATER CLOSETS -> 1.28 GALLONS/FLUSH
117. URINAL -> 0.5 GALLON/FLUSH
118. (EFFECTIVE DATE: 7/112016): THE COMBINED FLOW RATE OF ALL MULTIPLE S
(CG SECTION 4.302.2)
119. (EFFECTIVE DATE 7/l/2016): PLUMBING FIXTURES (WATER CLOSETS AND URI
4.303.3. (CG SECTION 4.303.3)
120. A KITCHEN FAUCET WILL USE MAXIMUM WATER FLOW RATE 1.5 GALLONS PE
(CG SECTION A4.303.1)
121. AUTOMATIC IRRIGATION SYSTEMS CONTROLLERS SHALL BE WEATHER-BASI
122. -MATERIAL CONSERVATION AND RESOURCES EFFICIENCY-
123. ANNULAR SPACES AROUND PIPES, ELECTRIC CABLES, CONDUITS OR OTHEE
CLOSING SUCH OPENINGS WITH CEMENT MORTAR, CONCRETE MASONRY Of
124. AN OPERATION AND MAINTENANCE MANUAL, CD, WEB -BASED REFERENCE (
THE FINAL INSPECTION. IT SHALL INCLUDE OPERATION AND MAINTENANCE 1
125. -ENVIRONMENTAL QUALITY-
126. ADHESIVES, SEALANTS AND CAULKS SHALL BE COMPLIANT WITH VOLATILE
127. PAINTS, STAINS, AND OTHER COATINGS SHALL BE COMPLIANT WITH VOC AN
128. AEROSOL PAINTS AND COATINGS SHALL BE COMPLIANT WITH PRODUCT WE
129. DOCUMENTATION SHALL BE PROVIDED TO VERIFY THAT COMPLIANT VOC Lip
130. CARPET AND CARPET SYSTEMS SHALL BE COMPLIANT WITH VOC LIMITS. (Cl
131. 50% OF FLOOR AREA RECEIVING RESILIENT FLOORING SHALL COMPLY WITH
LOW -EMITTING MATERIALS LIST OR BE CERTIFIED UNDER THE RESILIENT FL
132. PARTICLEBOARD, MEDIUM DENSITY FIBERBOARD (MDF) AND PLYWOOD USE
4.504.5)
133. MOISTURE CONTENT OF BUILDING MATERIALS USED IN WALL AND FLOOR FI
134. HIGHER THAN MERV 7 FILTERS SHALL BE INSTALLED ON CENTRAL OR VENT,
135. DUCT SYSTEMS ARE SIZED, DESIGNED AND EQUIPMENT IS SELECTED USING
136. A. ESTABLISH HEAT LOSS AND HEAT GAIN VALUES ACCORDING TO ACCA N
137. B. SIZE DUCT SYSTEMS ACCORDING TO ACCA 294) (MANUAL D) ASHRAE HA
138. C. SELECT HEATING AND COOLING EQUIPMENT ACCORDING TO ACCA 36S1
139. DUCT OPENINGS AND OTHER RELATED AIR DISTRIBUTION COMPONENT OPE
140. -INSTALLER AND SPECIAL INSPECTOR QUALIFICATIONS-
141. HVAC SYSTEM INSTALLERS SHALL BE TRAINED AND CERTIFIED OR WORK UI
SYSTEMS. (CG SECTION 702.1)
142. WHEN REQUIRED BY THE ENFORCING AGENCY, HVAC SPECIAL INSPECTORS
SECTION 702.2)
143. DOCUMENTATION WHICH SHOWS COMPLIANCE WITH CAL GREEN CODE INCL
INSPECTION REPORTS AND VERIFICATION SHALL BE
AVAILABLE AT THE FIN/
144. INSTALLATION CERTIFICATE OF COMPLIANCE (CITY ) IS REQUIRED TO I
145.
5/14/2018 City of Newport Beach Page 11 of 11
4:30:21PM INSP150 - Daily Inspection Request Report
Requested Inspection Date : 05/15/2018
Inspection Type : ENCROACH
Inspection Area : PW
Site Address : 3804 SANDUNE LN
Activity :
N2018-0261
SubType:
NEW
Status:
APPROVED
OWNER: REDDY NAVEEN S Phone:
APPLICANT: TERRA PRIMA INC Phone: 714-679-2002
CHERIE@TERRAPRIMAINC
Description : NEW DRIVEWAY APPROACH PER STD 162-L, NEW CURB AND GUTTER PER STD,
REMOVE CONCRETE STRIPS IN PARKWAY.
Requested Time: 5/15/2018 12:00:OOAM Requestor: WEBUSER
7146792002
Entered By: WEBUSER
Comments: AM -Pis call and give expected ETA.
Assigned to: zuz/uzzzzzzz'
Inspector: Date: 1 Time: ys PM
F:Wsers\PBW\Shared\E NCROACH\MASTERS\FORMS\InsoectorSheet doc
REPT131. Run Id: 4018
5/29/2018 City of Newport Beach Page 10 of 16
a:30:09PM INSP150 - Daily Inspection Request Report
Requested Inspection Date :
05/30/2018
Inspection Type :
ENCROACH
Inspection Area :
PW
Site Address :
3804 SANDUNE LN
Activity :
N2018-0261
SubType:
NEW
Status :
APPROVED
OWNER: REDDY NAVEEN S Phone:
APPLICANT: TERRA PRIMA INC Phone : 714-679-2002
CHERIE@TERRAPRIMAINC
Description : NEW DRIVEWAY APPROACH PER STD 162-L, NEW CURB AND GUTTER PER STD,
REMOVE CONCRETE STRIPS IN PARKWAY.
RequestedlnSpection(s) .r 1.z� Y
Item: 10250 FINAL - PW
Requested Time: 5/30/2018 12:00:OOAM
Entered By: WEBUSER
Comments: AM-Pls call to let us know your ETA.
Assigned to : zzzzzzzzzzz'
Requestor: WEBUSER
7146792002
Inspector: 4S Date: 5-3o - 1$ Time: '.Oo d9PM
Comments: 6C.JC91VTE Gr,"PCETJF Co..ULXre P&— P,%ULU4j7
F:\Users\PB\MShared\ENCROACH\MASTERS\FORMS\InsoectorSheel doc
REPT131. Run Id: 4018
-.WORKSHEET FOR ENCROACHMENT. PERMIT"
:. ,CITY OF•NEWPORT BEACH
: _PUBLIC WORKS DEPARTMENT
COMPLETE THE BELOW INFORMATION
PROJECT ADDRESS:
DETAILED DESCRIPTION OF PROPOSED WORK:
4o r
1N01. (Al cr��2_hnla '4� C()rnart 1010 r1refl-
u3f
APPLICANT: etc 9C)CO
Phone: ILt
Email Address: 1 C 1 ,
Mailing Address:
3
City/State/Zip:
OWNER: Ka Phone: +3
Email Address:
Mailing Address: City/State/Zip:
l
ALL CONTRACTOR.INFORMATION IS REQUIRED -PLEASE COMPLETE
CONTRACTOR:
Office Phone: I�t -p
Company (if different):
Jobsite Phone:
Other Phone:
Email Address:
Mailing Address:
3,2(t) kOE
City/State/Zip:
Ci Z'
State License Number & Class:
'Z $ '1 Expires: 3 31 1
City Busin ss License Number:
Expires:
i
WORKERS COMPENSATION INSURANCE - Certificate of Insurance (Section 3800 Labor Code)
Compan '1 501znrf Policy No: t)WC 100-72Ct0 Expires: 3Z%bq
Municipal Oerations: 949-644-3055
Utilities: 949-644-3011
Urban Forestry: 949-644-3083
FOR OFFICE USE ONLY
Special Conditions of Permit:
ADDITIONAL APPROVAL REQUIRED FROM THE FOLLOWING DEPARTMENTS
Utilities:
Municipal Operations
Traffic: Fire:
Other:
Engineering Technician:
Pe ialist
Date:
t
Permit No.
N2018-
f NseNpb IsnamalenmaMmaste epw Sheet AS
(0—liu—blic Works Department 949-644-3311
100 Civic Center Drive, Newport Beach, CA 92660