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[1l APPLIC (p+ey ❑ CURB CUT ❑ SEWER CONNECTION
Permit # E.P. Oo —�
Az4Ej ❑ STREET EXCAVATION ❑ WATER CONNECTION
Amount Fee Paid $l��i
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❑ UNDERGROUND UTILITIES --tT OTHER:
Receipt#
[2] ADDRESS OF WORK:
[3] APPpLICANT'S NAMES :ADDRESS: o Gg_ :AREA CODE:
sS�d(?G2A'r.G /</rt�TOrN Pir�r5r
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PHONE:
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[4] OWNER'S NAME: :ADDR3F�, GA,y51 :AREA CODE:
:PHONE: 09�w '-5_2 2� S
[5] CONTRACTOR'S NAME: :ADDRESS: Sr :Office Phone: (909
:Job Site Phon JQg 1Co_.p6�G
[6] APPLICANT HEREBY MAKES APPLICATION TO: a c.
- (SEE ATTACHED PLANS)
SPECIAL CONDITIONS OF APPROVAL BY CITY:
/REQUIRED
❑ 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 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] CONTRACTORS CITY BUSINESS LICENSE NO. 003/ [8] STATE LICENSE NO. 57665
[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.: Q S/ G' 6 o Company: Expiration,Date:'z /—o/
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
Workers 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)
[11] CONTRACTOR LICENSE EXEMPTION
❑ 1 am exemptfmm hiring a Conhactor as I am the OWNER of the property and am personally performing all work within the Public right-of-way.
Date: Applicant
(signature)
[12] HOLD HARMLESS STATEMENT
❑ 1 understand that I am locating minor encroachments within the City righWI-wayleasement It is my responsibility as the property owner to maintain the
encroachments. I will be responsIDle 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
Thesand conditions of this permit are printed on both sides of this form. Applicant hereby acknowledg that he as read
nd un n s sat t and condifi s an at a agrees to bide by Nem.
aL
J OWNERS OR AUTHORIZED AGENTS SI NATURE (DAT)
[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 APPROVAL REQUIRED
DATE SIGNATURE - TITLE
............. ..... ._...._..._.._........:_..._..------.._..--------
PERMIT ISSUED BY:
DATE ISSUED:EXPIRATION DATE OF PERMIT:
PERMIT DENIED:
White - Permit Pink -Temporary Office Copy Yellow - Applicant