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SM,dUe% ar M.sW EP -17-99 EP Form.xis \ \L�1 / J 1 ME EXHIBIT "A"
CITY OF NEWPORT BEACH ENCROACHMENT PER
(Please type or print legible. Press hard - makes 3 copies)
Permit # E.P. 400--le-o'
[i] APPLICATION FOR: ❑ CURB CUT SEWER CONNECTION
(CHECK ONE) ❑ STREET EXCAVATION ❑ WATER CONNECTION
Amount Fee Paid $ r9 0/
❑ UNDERGROUND UTILITIES ❑ OTHER:
Receipt# Z <A 1 45 4—
[2] AD—DRESS OF WORK: I
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[4] OWNER'S NAME: :ADDRESS: :AREA CODE:
:PHONE:
[ CQN jpR'$.jJAy1E: ;ADDRESS: :Office Ph'
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11 II1I//w.. JJIJ�Ir :Job Site P e: J ' V
[6] LICA T HEREBY MAKE? APPL�
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(SEE ATTACHED PLANS)
SPECIAL CON91TIONS OF APPROVAL REQUIRED BY CITY: �a l t ct('LL
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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 clear ncp over or under xisting 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 req Ired, 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
F ANY EXCAVATION AT 1-800-422-4133
[7] CONTRACTOR'S CITY BUSINESS LICENSE NO. [8] 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 Worker's Compensation Insurance or a Certified Copy thereof.
Policy No.: I3�2 gad Company: 'S -V06 5V OD Expiration Date: 61 Ott Vv
V V
Daae. Applicant:
(sig Lure)
[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 California. 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)
[31] CONTRACTOR LICENSE EXEMPTION
❑ 1 an 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 dghtvf-wayleasement. It is my responsibility as the property owner to maintain the
encroachments. I will be responsible for replacing the improvements if the City removes Nem for maintenance of utilities or other public need: and t, the
property owner shall indemnify and hold the City ha niess 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
Lands sai terms an nd" n nd that heabi e by Them. ` 1
J
OWNERS OR JUJI AGENTS SIGNATURE (DATE)
[14] * * * * * ES 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 OFFIC9 USE
DEPARTMENT
APPROVAL REQUIRED
DTE
SIGNATUR -TIT�LE .��^^
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PERMIT ISSUED BY
DATE ISSUED:'— 24 —Zo eo EXPIRATION DATE OF PERMIT:
PERMIT DENIED:
White - Permit Pink - Temporary Office Copy Yellow - Applicant
0M7 -:OF NEVE - ORT- BEACH'..
PUBLIC. WORKS: D kMi6N`I`
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(Sketch to be drawn in triplicate) 11- A 7 r,lIiI)_'
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Job Rddress
Owner
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(� Center line of STREI= t� N S"( A Lk'SC
221
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Rpplicant`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.