HomeMy WebLinkAboutN2000-0280SM��MMi kEPI 7-99 EP Form.zhs
White - Permit Pink - Temporary Office Copy Yellow - Applicant
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CITY OF NEWPORT BEACH ENCROACHMENT PERMIT
(Please type or print legible. Press hard - makes 3 copies)
Permit # E.P. Zacb - Z-60
[i] APPLICATION FOR: ❑ CURB CUT ❑ SEWER CONNECTION
(CHECK ONE) ❑ STREET EXCAVATION ❑ CONNECTION
Amount Fee Paid $�iC'0 F�
�WATER
❑ UNDERGROU DUTILITIES ®'OTHER:
Receipt#_ G t3 Z G> 7 1
[2] DDRESS OF WORK: Lf VD 6
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[ APL AME / �_V 1 /_ V ✓' �AREA CODE.
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A�TS4_\ N_ g'iV� PHONE -714
[ OWNER'S NAME: ;ADDRESS: :AREA CODE:
PHONE:
[ CO 'y'IyAM ;ADDRESS: - -- - :Office Phone:-- -- --- -
�(/J, -Job Site Phone:
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[6] APPLICANT HEREBY MAKES APPLIC TION TO:
(SEER ACHED 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 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 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
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)
❑ 1 certify that I have a Certificatof consent to self -insure, or Certificate of Workers CompensationInsurance or a Certified Copy thereof.o/ 100
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PolicyNo.:- 134 ) X� Com �A '`-' 1� v � D
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y:_ Expiration Date:�1
DatA Applicant:
(sig atur
10] CERTIFICAT 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 Cal'domia. 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.
Date: Applicant
(signature)
12] HOLD HARMLESS STATEMENT
❑ I understand that I am locating minor encroachments within the City right-0f-way/easement. It is my responsibility as the property owner to manlain the
encroachments. I will be responsible for replacing the improvements if the Gty removes them for maintenance of utilities or other public need; and I, the
property owner shall indemnify and hold the City hapless 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
e terms and conditions pTis permit are printed on both sides of this form. Applicant hereby acknowledges that he has read
n derstand aid terns d dition and that he agre s o abid em. `
1. -a-V D
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OWNERS OR A TH ZED AGENTS 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 I DATE SIGNATURE - TITLE
PERMIT ISSUED BY:
DATE ISSUED: P1 Z z_ L o oc XPIRATION DATE OF PERMIT:
PERMIT DENIED:
White - Permit Pink - Temporary Office Copy Yellow - Applicant
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