HomeMy WebLinkAboutN2000-0244Sharea\E:voacMMa rot EN 7-99 EP Form.xls
CITY OF NEWPORT BEACH ENCROACHMENT P R
(Please type or print legible. Press hard - makes 3 copies)
f>
[S] APPLICATION FOR: ❑ CURB CUT ❑ SEWER CONNECTION7FeePaid
(CHECK ONE) ❑ STREET EXCAVATION ❑ WATER CONNECTION❑
UNDERGROUND UTILITIES ❑ OTHER:
[2] ADDRESSryOAF WORK:
Dr�I`� t= i
1(�J
[3— IIED� _ 1 1D�E :PHONE.
[4] OWNER'S NAME: :ADDRESS: :AREA CODE:
:PHONE:
[9p1wjQE: ADDRESS:
Office Phone:
C*ob
; Site Phone (� V
[61JPPLICNTHEREBY NINCES APPLICATION T:
CJS JEvs(bJC
t 1
_
(SEE ATTACHED PLANS)
SPECIAL CONDITIONS OF APPROVAL REQUIRED BY CITY:
r i
(11 UU
❑ Locate 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 staff 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. 15 T I W 1,11 [s] STATE LICENSE NO.
[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.
OD
3 (9 (J teL�
' U � � y \
Policy l Company: `-' Expiration Date:
►1N��'o..:
_
Dart§! Applicant:
(signature)
[10] CERTIFICATE OF EXEMPTION
(Section 3800 Labor Code)
❑ 1 cert8y 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 Calffomia. If, a If, 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.
Data: 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 ublities or other public need: and I, the
property owner shall indemnify and hold the City 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 conditions of this permit are printed on both sides of this form. Applicant hereby acknowledges that he has read
and unnds saJrid t rms and 'on d at he ag e y em.
aU vn�C�nUb
OWNERS OR AUTH RIZ A ENTS SIGNATURE (DATE)
[14] * * * * * TREES WITHIN THE CITY'S RIGHT-OF-WAY * * * * *
NO TREES WITHIN THE CRY'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 APPROVAL REQUIRED DATE SIGNATURE -TTTLE
V IF
i✓
PERMIT ISSUED BY:
DATE ISSUED: �3o -2coa-2000 EXPIRATION DATE OF PERMIT:
PERMIT DENIED:
White - Permit Pink - Temporary Office Copy
Yellow -Applicant
.. CI Ty_: OF -=NEWPORT BEACH --
PUBLIC
EACH- PUBLIC_ WORKS: -DEPARTMENT-
SKETCH
DEPARTMEN I`SKETCH FOR ENCROKHtM PERMIT NO. EP—
LEGEND. (Sketch to be drawn -in triplicate) �� ® pp
(�
+ = TREE
!t~ POHM .POLE
Q = .SBER Ia-UM T
Q WATER H=TER BOX
1k) Center 1
Job Address
Owner K `_� P-, lucc_�
Telephone No. -71'A- 4) z= 1 DQ
IN
s'
of�» e
l V\ s —\'T ,S' GE
°�
--�--r-------=------r•-=------------r-fit
I� 2`
I I
I I
I I
20 via
Applicant's Signature Date
\ 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: