HomeMy WebLinkAboutN2000-0099S MdWjKnwxhV V Vs 47-99 EP Furm.As
J J EXHIBIT "A
CITY OF NEWPORT BEACH ENCROACHMENT PERMIT
(Please type or print legible. Press hard - makes 3 copies)
Permit # E.P. n - o 9—
aid $LS
[i] APPLICATION FOR: CURB CUT MEFLE E TION
(CHECK ONE) ❑ STREET EXCAVATION COT
❑ UNDERGROUND UTILITIES
[2] ADDRESS OF WORK: 3 i Z i
[3] APPLICANTS NAME :ADDRESS:;AREA CODE:
-.e_:—J1.2.._ RO(PHONE:
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[4] OWNER'S �NA`ME: Iv� ,pp ADDRESS: :AREA CODE A
)N �(J��i,J`14- u_Me :PHONE;�Y-
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[5] CONTRACTOR'S NAME: ;ADDRESS: ;Office Phone: (Z l4�
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V �JYL ; % Z 3 Cy ]'1/M115 (.tiA. C r %)i . Job Site Phone: �! I7 —487-
8 -[6]
[61 APPLICANT HEREBY MAKES APPLICATION TO: f
/ka"d ci✓ E/L L� S�.J
(SEE ATTACHED PLANS)
SPECIAL CONDITIONS OF APPROVAL REQUIRED BY CITY:
12,
❑ Locate and pothole existing City owned utilities (is: 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.L[8] STATE LICENSE NO. C
[9] WORKERS COMPENSATION INSURANCE
CERTIFICATE OF INSURANCE
(Section 3800 Labor Code)
I certify that I have Certificate of to self -insure, or Certificates ofWorkers Insurance or a Certified Copy thereof.
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Policy No.: l (i I J l: Company: I Y d land I a J• Expiration Date: n
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Data: � p licant
(signature)
[10] CERTIFICATE OF EXEMPTION
(Section 3800 Labor Code)
❑ 1 ce" 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)
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 nghtof-way.
Date: Applicant:
(signature)
12] HOLD HARMLESS STATEMENT
❑ 1 understand that I am locating minor encroachments within the city rightof-wayleasement It is my responsibility as the property owner to maintain the
encroachments. I will be responsible for replacing the improvements 0 the City removes them for maintenance of utilities or other public need; and I, the
properly owner shall indemnity and hod the City hamlless for any liability associated with the minor encroachments.
Date: owner Sipnalure:
13] «««< 24 HOUR ADVANCE NOTICE IS REQUIRED FOR ALL INSPECTIONS »»»>
CALL (949) 644-3311
The and ition mrit are printed on both sides of this form. Applicant hereby acknowledges that he has read
a undo sad the agrees to abide by them.
z/ /mac
OWNERS OR AUTHORIZED AGENTS SIGNATURE (DATE)
14] * * * * * TREES WITHIN THE CITY'S RIGHT-OF-WAY * * * * *
NO TREES WITHIN THE CRUS 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: f
DATE ISSUED: 7 .' 4 / EXPIRATION DATE OF PERMIT:
PERMIT DENIED:
White - Permit Pink - Temporary Office Copy Yellow - Applicant
CITE' OF NEWPORT BEACH EXHIBIT 'B'
PUBLIC WORKS DEPARTMEN- I OF 2
SKETCH FOR ENCROACHMENT PERMIT NO. EP -
LEGEND:
= TREE Job Address
= POWER POLE Owner
SEWER CLEANOUT
WATER METER BOX Telephone No. fy49 07ZI —Z U- ,-)
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Exlsting Curb and Gutter
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Center tine of street
pp icnn 's mgnature Do te
Please
make a
sketch of the immediate
vicinity showing all property tines, dimensions
street
names,
location of trees,
tight
standards, fire hydrants, parking meters or
other
existing
improvements which
might
be affected by the proposed encroachments.
<SEE
REVERSE
SIDE)
Works
shall be
done according to
City
Specifications and is subject to City inspection
Requested Inspect Date:
Tue��February 26, 2002
Assigned To:
Inspection Type:
ENCROACH
Inspection Area:
PW
Site Address:
<None Listed>
312 SIGNAL RD
A/P/D Information
Activity: N2000-0099 Type: ENCROACH Sub Type: NEW Status: APPROVED
Const Type: Occupancy: Use: Insp Area: PW
Applicant: KELLER & SONS CONSTRUCTION CO Phone: 714631-5298
Description: NEW DRIVE APPROACH
Reauested Insoection(s
Item: 10250 FINAL -PW Requested Time: 10:00 AM
Requestor: SHARI CLEAN OUT OLD PERMITS Phone:
Comments: FINAL ON TREE REMOVAL PER GS CONDITIONS
Assigned To: Entered By: SROOKS K
Action: Time Exp:
Inspector:
Comments:
Date: Time:/h(A- PM
REPT131 Run Id: 214