HomeMy WebLinkAboutN2000-0363ava¢e�vmasars%tv-i -" cr rorm.eis jr,
C1117111111 -A--
CITY OF NEWPORT BEACH ENCROACHMENT PERMIT'
.
(Please type or print legible. Press hard - makes 3 Copies)
Permit # E.P. +? - V, 3
[1] APPLICATION FOR: CURB CUT ❑ SEWER CONNECTION
(CHECK ONE) ❑ STREET EXCAVATION ❑WATER CONNECTION
Amount Fee Paid $' '
❑ UNDERGROUND UTILITIES E OTHER:
Receipt# -
[2] ADDRESS OF WORK: 170 91 &qX4 7-r. -4*.001
r Y�—
[3] APPLICANT -'S NAME/ :ADDRESS: G / /,fir-� AREA CODE: %%Y 77yZ7i
3a A F ES�Y/d,�tvP Ilei 'PHONE:
1[4]
OWNER'S NAME: ;ADDRESS, 11aG7 P!Gr/a Fr] JG �y Lr7 ;AREA CODE:
; � OA95 CSal ( leu 7r 'YID . _PHONE:
[S] CONTRACTOR'S NAME: i ;ADDRESS: C ;OfficePhone: VV77y 2 7a
a��
✓ -Job Site Phone:
[6] APPLICANT REBY MAK AP LICATION TO:
r.
(SEE ATTACHED PLANS)
SPECIAL CONDITIONS OF APPROVAL REQUIRED BY CITY:
❑ 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] CONTRACTOR'S CITY BUSINESS LICENSE NO. [B] STATE LICENSE NO.
191 WORKERS COMPENSATION INSURANCE
CERTIFICATE OF INSURANCE
(Section 3800 Labor Code)
❑ I certify that I have a Certificate of consent to or Certificate of Worker's Compensation Insurance or a Certified Copy thereof.
)self-inssurre,
Policy No.: 70/ / !00 3/ Company: �7 �]�t/T 61 iA Expiration Date:_9 2�0/
nn91—C
Date:�114pplicant C�_
(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 Stale Labor Code, I must comply with the provisigpcoj n 3700, or this permit shall be deemed revoked.
Date:�[0Applicent_ ,��o
(signature)
[11] CONTRACTOR LICENSE EXEMPTION
❑ 1 am exempt from hiring a Contractor as I am the OWNER of the propeM and am personally performing all work within the Public nghWf-way.
Date: Applicant:
(signature)
12] HOLD HARMLESS STATEMENT
❑ 1 understand that I am locating minor encroachments within the City rightuf-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 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
The terms and conditions of this permit are printed on both sides of this form. Applicant hereby acknowledges that he has read
and understands said terms ndi' n that he agrees to abide by them.
OWNERS OR AUTHORIZED AGENTS SIGNATURE (DATE)
14] * * * * * TREES WITHIN THE CITY'S RIGHT-OF-WAY * * * * *
NO TREES WITHIN THE CITrS 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: '?so -o EXPIRATION DATE OF PERMIT:
PERMIT DENIED:
White - Permit Pink - Temporary Office Copy Yellow - Applicant
� N
� w
. .Az
-34
N
s
cmc
V