HomeMy WebLinkAboutN2000-0298IWOMsxu
EXHIIBIT A�
CITY OF NEWPORT BEACH ENCROACHMENT PERMIT
FOR OFFICE USE ONLY,
(Please type or print. Press hard - make 3 copies)
Permit #
(1) APPLICATION FOR: ❑ CURB CUT ❑ SEWER CONNECTION
(CHECK ONE) ❑ STREET EXCAVATION ❑ WATER C NECTION
Amount Fee Paid $
❑ UNDERGROUND UTILITIES OTHER
Receipt If 2 4 3 5 0 5
(2) ADDRESS OF WORK: Cl
(3) APPUCANT'SN E_-_ :ADDRESS:
:PHONE:
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(4) OWNER'S NAME: ADDRESS:j?O S'.0%.we -1 w
'PHONE:'/ SIX p-fpf--
(5) CONTRACTOR'SNAMF- :ADDRESS:
1 is Phone: t%
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:Job Sit Phone:
(6) APPLICANT HEREBY MAKES ACATION Ti D� , EF fiY
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e5kANew IF G-rL- C_ ` 1— (o
tASe\) p P (Lev p J iEE ATTACHED PLANS) 1cR T
SPECIAL CONDITIONS OF APPROVAL REQ IRED BY CITY:
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ocate and pothole existing City owned utilities (ie: water, wer, or street lighting conduits) to erify locations prior to s art of any work. Maintain a
one (1) foot clear, er o der stip fly owned 'IfitiN To arrange for inspectiynocall connections to CBy Utilities or'rf a conflict should ocar
please contacV•f�(L. of the Uti "es Department, 48 horior to start of any work at (714) 644.3011. in addition, when
a sewer cleanout is required, V.C.P. or P.V.C. SDR35 shall be used ' h a 4TT box overeanout riser.
D----'' " ALL UNDERGROUND WORK SHALL PERFOR D BY A LICENSED CONTRACTOR—
R ���ONTACT UNDERGROUND SERVIC LERT" T LEAST48 HOURS IN ADVANCE
F sh; vn 1 5 F ANY EX VAT ON AT 1-800-422-4733
(7) CONTRACTOR'S CITY BUSINESS LICENSE NO. (8) STATE LICENSE NO. -O
aty4Y1B � (9) WORKERS COMPENSATION SURANCE
CERTIFICATE OF INSU N
(Section 3800 Labor Cade)
❑ 1 certify that I have a Certificate of consent to self -insure, or Cert6cate of Worker' Compeennsa' Insurance or a Certified Copy thereof.
Policy Na: //�933o '- 9� Company: �.I/ Expiration Date: eG
❑ Certified Copy hereby furnished
Date: Applicant:
(sign re)
(10) CERTIFICATE O EXEMPTION
(Section 3 0 Labor Code)
❑ 1 certify that in the performance of the work for which this permit is issu , I shall not employ any person in any nner so as to become subjects
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to the Worker's Compensation Laws of California. '� O
fl, after signing this certficate I become subject to the Worker's Com nsation provisions of the State Labor Code, I 'must comply with the provio _$
Section 3700 or this permit shall be deemed revoked.o m
41
Date: Applicant:
(signature)
01) CONTRACTPIR LICENSE EXEMPTION G) FL
❑ 1 am exempt from hiring a Contractor as I am the 0 NER the property and am personally performing all work within the Public ' ht of -way. m 0
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Date: Applicant: C4 O
(signature) m e
(12) HOLD HARMLESS STATEMENT
❑ I understand that I am locating minor encroachments within the City right-of-way/easement. It is my responsibility as the property owner to mailpirMe
encroachments. I will be responsible for replacing improvements if the City removes them for maintenance of utilities or other public need; Wd Phe'
'Pe
property o nen Oall indemnify and hold the C' armless for a liabilk ciated with the minor encroachments. o
Date: g a y o0 Owner signature: D) 0 a
(13) «««< 24 HOUR ADVAirCE NOTICE ISR(4UIRED FOR ALL INSPECTIONS »»»> m v m
CALL (714) 644-3311 =
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The terms and conditions of this permit are printed on both sides of this form. Applicant hereby acknowledges that he has rT08)
and understa said terms and conditionsand thathe agrees to abide by them.
7
OW NERS OR AUTHORIZED AGENTS SIGNATURE (DATE)
SPACE BELOW THIS LINE FOR OFFICE USE
DEPARTMENT APPROVAL REQUIRED DATE SIGNATURE -TITLE
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PERMIT ISSUED BY;�T ,,qrrzt a&z y
DATE ISSUED: — 20k:7a EXPIRATION DATE OF PERMIT:
PERMIT DENIED:
White - Permit Pink - Temporary Office Copy Yellow - Applicant