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EXHIBIT "A"
CITY OF NEWPORT BEACH ENCROACHMENT PERMIT r
(Please type or print legible. Press hard - makes 3 copies)
[3] APPLICATION FOR: CURB CUT ermit#E.P.-- 7-33
(CHECK ONE) ❑ STREET EXCAVATION COUmount Fee Paid $ 3
❑ UNDERGROUND UTILITIES �„ OTHER: Receipt# L.
[2] ADDRESS OF WORK: 1 0 2T , 9.g .
APPLICANT'S NAME;ADDRESS. p " :AREA CODE:
—V SS L A^ -r) coIci1 MJ,PHONE:c[+f o-'
O SS -7 1
[4] OWNER'S NAME:'ADDRESS: ;AREA CODE: /
:PHONE: -A-+,n'T,) If
[51 CONTRACTOR'S NAME: :ADDRESS:;Office Phone: �S
� ^ Job Site Phone: _��
[6] APPLICANT HEREBY MAKES APPLICATION TO: o V -Z- Q-+ � 6Z1 tl` 11
L-QrIA O 1 Ck�i-Q'S....-. A-tAl ^ l.W A-1.4L� L.Tt
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SPECIAL CONDITIONS OF APPROVAL REQUIRED BY CITY:
C- 4 C F- th of 7- L/ 4- P •V N E L
g'Cocate 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) fool cleaarampi ove/r�[, unde_rei_stii2g_Cittyy owned utilities. To arrange for inspection of all connections to City Utilities or if a conflict should occur
please coma ' !Z ' i7 l ZZ&*e 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 47 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. T cf 0 O S 09.1 [8] STATE LICENSE NO.
[9] WORKERS COMPENSATION INSURANCE
CERTIFICATE OF INSURANCE
(Section 3800 Labor Code) �� r ' ` PL' I�---
❑ I certify that I have a Certificate of consent to self -insure, or Certificate of Worker's Compensation Insurance or a Certified Copy thereof.
Policy No.: Company: Expiration Date:
Date: Applicant:
(signature)
[30] CERTIFICATE OF EXEMPTION
(Section 3800 Labor Code)
I 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
Workers Compensation laws of California, If, aIf, after signing this this certificate I become subject to the Workers Compensation provisions of
the State 4abor Code, I must comply with the p e , 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 -M -way.
Date: Applicant
(signature)
12] HOLD HARMLESS STATEMENT
❑ 1 understand that I am locating minor encroachments within the City right-of-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 I, the
property owner shall indemnify and hold the Off harmless for any liability associated with the minor encroachments.
Date: Owner Signature:
13] «««< 24 HOUR ADVANCE NOTICE IS REQUIRED FOR ALL INSPECTIONS »»»>
CALL(949)644-3311
The terms and rmit are printed on both sides of this form. Applicant hereby acknowledges t the has read
and unders said s an s that he agrees abi em.
� OG -
OW OR HORIZED 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
DEPARTMENT AP AL EQUIRED DATE SIGNATURE - TITLE-
h
�MIT ISSUED BY:
E ISSUED: 6 - - zo 0o EXPIRATION DATE OF PERMIT:
MIT DENIED:
White - Permit Pink - Temporary Office Copy Yellow - Applicant
CITY OF NEWPORT BEACH EXHIBIT 'B'
PUBLIC WORKS DEPARTMENT I OF 2
SKETCH FOR ENCROACHMENT PERMIT NO, EP- 00
LEGEND: Q
+ = TREE Job Address [116> PO t 46£x, K&
f = POWER POLE Owner 113L Pum M13 ,,l L• LC,
Q = SEWER CLEANOUT Telephone No.
Q = WATER METER BOX
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Existing Curb an Gutter
TT) °s '�e�'c'% f�21inI 6�PPILc�✓�c k4 �SiD S«/�tiL.
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Center line of street -� _ _ .
2,l lot,
n e
Please
make a
sketch of the Immediate
vicinity showing all property lines, dimensions
street
names,
location of trees,
light
standards, fire hydrants, parking meters or
other
existing
Improvements which
might
be affected by the proposed encroachments.
(SEE
REVERSE SIDE)
Works
shall be
done according to
City
Specifications and Is subject to City inspection.