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Home My WebLink AboutN2000-0023SnaredlEnvwN\NastasleFd 7-99 EP Fonn.xls czm EXHIBIT A CITY OF NEWPORT BEACH ENCROACHMENT PERMIT (Please type or print legible. Press hard - makes 3 copies) Permit#E.P.r1z4�- o0 [1] APPLICATION FOR: ❑ CURB CUT ❑ SEWER CONNECTION (CHECK ONE) ❑ STREET EXCAVATION M WATER CONNECTION Amount Fee Paid $ 1 a%r E.rD ❑ UNDERGROUND UTILITIES ❑ OTHER: Receipt# --- [2] ADDRESS OFWORK:X,,i,LYY,ry.1-3fr A!t- [3] APPLICANT'S NAME :ADDRESS: %$ S-/ ,C- ,�j �i Y/S a,� AREA CODE: / cf T w/ L e :PHONE:. ��Y_._ [4]] OWNER'S NAME: AR CODE: 9 rf $.$ O J N�a�v�Ooi��- /:ADDRESS: AA�,�i-vEA (� I -le- ..J e- It/_;PHONE: [5] CONTRACT/OR'S NAME: ;ADDRESS: Phone: �r /9 ile eq� ,/ s 6. IJob Site Phone: [6] APPLICANT HEREBY MAKES APPLICATION VO: n P — \ S- L -- a> 6 C- g (SEE ATTACHED PLANS) SPECIAL CONDITIO/fN'S OF APPROVAL REQUIRED BY CITY: rA P�C.L %Grx ax++s.L Gli'�r%'i�i e r s. h r S wbf be .00 -fin - 3 3 J p ❑ Locale and pothole existing City owned utilities (ie: water, sewer, or street lighting conduits) to verify locations prior to start of any work. Maintain a one (1) foot clearance over or under existing City owned utilities. To arrange for inspection of all connections to City Utilities or if a conflict should occur please contact of the Utilities Department, 48 hours prior to start of any work at (949) 644-3011. In add when a sewer cleanout is required, V.C.P, or P.V.C. SDR35 shall be used with a 4TT box over the cleanout riser. ** ALL UNDERGROUND WORK SHALL BE PERFORMED BY A LICENSED CONTRACTOR** CONTACT "UNDERGROUND SERVICE ALERT" AT LEAST 48 HOURS IN ADVANCE OF ANY EXCAVATION AT 1-800-422-4133 [7] CONTRACTOR'S CITY BUSINESS LICENSE NO.,6 rJ9 D V Z -3y3 [8] STATE LICENSE NO. 5.7 [9] WORKERS COMPENSATION INSURANCE CERTIFICATE OF INSURANCE (Section 3800 Labor Code) ❑ 1 certify that I have a Certificate of consent to self -insure, or Certificate of Workers Compensation Insurance or a Certified Copy thereof. Policy No.: 1-5---Y Z -3 /1— Company: -5 4 Expiration. Date: Date: - Applicant - (signature) [10] CERTIFICATE OF EXEMPTION (Section 3800 Labor Code) ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of Calffomia. If, aIf, after signing this this certificate I become subject to the Worker's Compensation provisions of the State Labor Code, I must comply with the provisions of Section 3700, or this permit shall be deemed revoked. Date: Applicant: (signature) [11] CONTRACTOR LICENSE EXEMPTION ❑ 1 am exempt from hiring a Contractor as I am the OWNER of the property and am personally performing all work within the Public right-of-way. Dale: Applicant (signature) [12] HOLD HARMLESS STATEMENT ❑ 1 understand that I am locating minor encroachments within the City dghWf-way/easement. It is my responsibility as the property owner to maintain the encroachments. I will be responsible for replacing the improvements if the City removes them for maintenance of utilities or other public need; and 1, the property owner shall indemnify and hold the City harmless for any liability associated with the minor encroachments. Dale: Owner Signature: [13] «««< 24 HOUR ADVANCE NOTICE IS REQUIRED FOR ALL INSPECTIONS »»»> CALL(949)644-3311 The terms and conditions of this permit are printed on both sides of this form. Applicant hereby acknowledges that he has read and understands said terms and conditions and that he agrees to abide by them. - �'9 C> io �i��1 OWMEOWOR AUTHORIZED AGENTS SIGNATURE (DATE) [14] * * * * * TREES WITHIN THE CITY'S RIGHT-OF-WAY * * * * * NO TREES WITHIN THE CITY'S RIGHT-OF-WAY SHALL BE PLANTED, REMOVED OR RELOCATED WITHOUT PRIOR APPROVAL FROM THE GENERAL SERVICES DEPARTMENT SPACE BELOW THIS LINE FOR OFFICE USE D PARTMENT APPROVAL REQUIRED ATE I SI NAT RE -TITLE PERMIT ISSUED BY: DATE ISSUED: /—Zo— zamb PIRATlON DATE OF PERMIT: PERMIT DENIED: White - Permit Pink - Temporary Office Copy Yellow - Applicant 'S a F TO BE COMPLETED BY FIELD PERSONNEL Inspector - J' r -T -T ,M61 6 F Contractor: INSPECTIONS . DATE TIME COMMENTS 2.p N v r 00 (o , 1S AM fN O lite- J once TERMS AND CONDITIONS f. Encroachment permits shall be taken out in the name of the owner of the benefited property and signed by the owner or authorized agent. An approved copy of the 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. 2. The Permittee agrees to defend, indemnify and hold the City, its authorized agent, officers, representatives and employees harmless from any responsibility, liability, suite or action of any description arising out of any accident, loss or damage to persons of propert�, occurring as a proximate result of any work undertaken under this permit. 3. All work shall be done in accordance with the approved plans, and the Standard Special Provisions and Standard Drawing of the City of Newport Beach, and in compliance with all applicable State laws and City ordinances. 4. Permittee guarantees all work performed under this permit to be free of hidden and latent defects. Any failures will be corrected within two weeks after notification to the satisfaction of the Director of Public Works. 5. All construction within public rights-of-way must be performed by licensed contractors, unless waived by the :Public. Works Department. 6. Contractors shall obtain permits to perform excavation or trench work from the California Division of Industrial Safety prior to commencing underground construction as required by State law. Trench excavation and backfill shall conform to Section 306-1 of the City's Standard Special Provisions. Walls and faces of all excavations over 5 feet in depth shall be effectively protected by a shoring system, sloping of the ground, or other equivalent means. Trenches less than 5 feet in depth shall be guarded when hazardous ground movement may be expected. 7. All work must be inspected by the Public Works Department. Forms and subgrades must be inspected and approved before concrete is ordered. Sewer, pipelines and subgrade construction must be inspected and approved before backfilling. Public Works inspectors are available during working hours upon 24 hours advanced notice. Call (949) 644-3311 to arrange for an inspection. Separate Utilities Department inspections may be required. It shall be. the Permittee's responsibility to restore improvements (i.e. street pavement, sidewalk, when applicable sprinklers, etc. within 72 hours after utility work has been completed and backfilled.. In addition, all sidewalk replacement shall be done in full panels. 8. All utilities connections must be inspected by the Utilities Department prior to backfill. The applicant shall notify the Utilities Department at (949) 644-3011 at least 72 hours in advance of work for utility inspections. In addition, all trench restoration must be inspected by the Public Works Department at (949) 644-3311. No utility installation(s) shall be allowed over or within 5' of City's Utilities, unless approved by the Engineer. 9. Barricades must be provided and maintained around all trenches, excavations and obstructions. Barricades must be properly lighted. All signs, flags, lights and other warning and safety devices shall conform to the requirements of the current "Manual of Warning Signs, Sights and Other Devices for the Use in Performance of Work Upon Highways", issued by the California Department of Public Works. If the applicant does not have barricades, barricades can be obtained from the City at a charge of $10.00 per barricade per day, with a minimum charge of $35.00. It is the responsibility of the applicant to place barricades to protect the general public. Access to fire hydrants shall be maintained at all times. 10. All work within or near beach sensitive areas will not be allow during Easter vacation, Memorial Day weekend, summer between June 151h and September le, and Christmas Vacation from December 191" to January 1�, unless approved by the Engineer. 11. Prior to undertaking any work which will extend into the traffic lanes and impede the normal flow of traffic, the applicant must first secure the written approval from the License Supervisor, who will notify the Police and Fire Departments prior to closing the streets. Applicant must maintain access to fire, police and emergency vehicles. Traffic Control as a minimum must be per Work Area Traffic Control Handbook (WATCH). No nighttime closures, unless approved by the Engineer. Any lane(s) closure in a major street will only be allowed between 9:00 a.m. and 3:00 p.m., unless approved by the Engineer. Any work affecting the State Highway's traffic or within the State Highway right-of-way will require a Caltrans Permit. All vehicles shall be lawfully parked. 12. The applicant must notify the. gas„electric, telephone and cablevision companies before starting any underground construction. Call underground service alert at 1-800-4224133 at least 48 hours before digging. Notify all affected residents 24 hours in advance of restricted access and any construction inconveniences. 13. Refuse or unused materials shall be removed within 24 hours after completion of the work. If materials are not removed, the City may remove the materials and bill the applicant. Coordinate alley closures with City's refuse pick-up days so service is not interrupted, call (949) 644-3066 for the trash collection schedule. 14. The driveway approach shall be removed, and the curb and,gutter replaced at the applicant's expense. 15. Any above ground facilities will require Public Works Departmerit approval and documented approval from the adjacent property owner(s). , f.\users\p6wNhved\wcroacL4,ustcrsltems9o.tloc