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Home My WebLink AboutN2000-0137citQMMFn^oad114asres\E5-17-99 EP Form.As CYLITBTT ^A^ CITY OF NEWPORT BEACH ENCROACHMENT PERMIT (Please type or print legible. Press hard - makes 3 copies) N2000- Permit # E.P. - ori. —L3 [i] APPLICATION FOR: ❑ CURB CUT ❑ SEWER CONNECTION (CHECK ONE) 11 STREET EXCAVATION 11 WATERCONNECTION Amount Fee Paid $ 4 7i. ' c ❑ UNDERGROUND UTILITIES ❑ OTHER: Receipt #mss -rte [2] ADDRESS OF WORK: 313 ONYX AVE [3NAME :AREA CODE: ([j RILBRIDEP.O. BOX 3341 NEWPORTGBEACH CA 92659 :PHONE [4 [4] OWNER'S NAME: :ADDRESS: :AREA CODE: PHONE: ^� [5] CONTRACTOR'S NAME: ;ADDRESS: ;Office Phone: L S RvrCJMDQ :Job Site Phone: [6]ALICHEREBYKE I CIONE :0 VV 5-V+A[9DJ0N Q S —\ oto - L . - (SEE ATTACHED PLANS) SPECIAL CONDITIONS OF APPROVAL REQUIRED BY CITY: Coate and pothole existing City owned utilities (ie: water, sewer, or street lighting conduits) to verfly locations prior to start of any work. Maintain a I one (1) foot deara,n� ver or under ez stin City owned utilities. To arrange for inspection of all connections to City Utilities or if a conflict should occur please contact /ef of the Utilities Department, 48 hours prior to start of any work at (949) 644-3011. In add when a sewer deanout 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. RT9601 4951 [8] STATE LICENSE NO. [9] WORKERS COMPENSATION INSURANCE CERTIFICATE OF INSURANCE (Section 3800 Labor Code) ❑ 1 certify that I have a Certificate of consent to self4nsure, or Certificate of Worker's Compensation Insurance or a Certified Copy thereof. j2c UI /� 1 3 V 1 5 t" V D ° V° Policy No.: Company: Expiration. Date: DSS° M 1 Dater 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, aIf, after signing this this Certificate I become subject to the Worker's Compensation provisions of the State Labor Code, I must comply vidh the provisions of Section 3700, or this permit shall be deemed revoked. Date: Applicant (signature) 11] CONTRACTOR LICENSE EXEMPTION ❑ 1 am examptfiom 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) 121 HOLD HARMLESS STATEMENT ❑ 1 understand that I am tocafng minor enaoachments within the City rightof-way/easement It is my responsibility as the propady owner to maintain the encroachments. 1 will be responsible for replacing the improvements Hthe City removes them for maintenance of utilities or other public need; and I, the property owner shall indemnify and hold the Gly harmless for any liability associated with the minor encroachments. Date: Owner Signature: 131 «««< 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 -andunde nds said to an onditio s and th c anraes bide by them. OWNERS O AUIT ORIZED AGENTS SIGNATURE (DATE) 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 C— Yes------- -- DD (�Z, - PERMIT' ISSUED BY: DATE ISSUED: /EXPIRATION DATE OF PERMIT": PERMIT DENIED: White - Permit Pink - Temporary Office Copy Yellow - Applicant SharM\Ercmadi\Masfas\EP-I 7-99 EP rrorm.xls 90MR� FFFM c H CITY OF NEWPORT BEACH ENCROACHMENT PERMIT 'x (Please type or print legible. Press hard - makes 3 copies) Permit # E.P. 24,490 —el [3] APPLICATION FOR: ❑ CURB CUT Cl SEWER CONNECTION (CHECK ONE) ❑ STREET EXCAVATION ❑ WATER CONNECTION Amount Fee Paid s J-5. ❑ UNDERGROUND UTILITIES OTHER: ipt# h Z.L [2] ADDRESS OF WORK: 10?2c [3] /IBP, LICANTS NAME ADDRE�S�S: � ,AREA CODE: [/ .t�D_K :PHONE:�O [4] OWNER'S NAME: :ADDRESS: :AREA CODE: >r'rj� —G 7 IPHONE: [S OOiNTRACTOR'S NAME: �L :ADDRESS: 7<f"c-f254Z ;Office Phone: IP�_ — ;Job Site Phone:,6 V:�'' [6] APPLICANT HEREBY MAKES APPLICATION TO:l✓ — r $ 0 104— 4 - (SEE (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 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 47 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. —6,57 1 [B] STATE LICENSE NO. —�- 191 WORKERS COMPENSATION INSURANCE CERTIFICATE OF INSURANCE (Section 3800 Labor Code) 0`11 cert fy that II a Certificate of consent to self -insure, or Certificate of Workers Compensation Insurance or a Certified Copy thereof. 7htaavvvee Policy No.: / / y�3� — Co ny: VL Expiration Date:_' Applicant g — i p / n (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 Califomia. If, aIf, 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 nghW-way. Date: Applicant: (signature) [12] HOLD HARMLESS STATEMENT ❑ 1 understand that I am locating minor encroachments within the City nght-0f-way/easement 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. Date: 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 and conditions and 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 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:1 DATE ISSUED: a v EXPIRATION DATE OF PERMIT: PERMIT DENIED: White - Permit Pink - Temporary Office Copy Yellow - Applicant CITY OF NEWPORT BEACH PUBLIC WORKS DEPARTMENT 1 OF 2 SKETCH FOR ENCROACHMENT PERMIT NO. EP- 3U LEGEND, + = TREE Job Address f = POWER POLE Owner QreGn lC, ,/� A= SEWER CLEANOUT Telephone Na. 1/49- Q = WATER METER BOX II l I I II I I II � II j II II I I II • �� cx. s,de wax --- --- _= — ------ - Existing Curb and Gutter 6 � •k Center line of street Cpp. I1I' 1 1 f Please make a sketch of the Immediate vicinity showing all property lines, dimensions street names, location of trees, light 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.