HomeMy WebLinkAboutN2000-0155eha�\Fn"wchVma9eal®4 7-99 EP Farm.xls
EXHIBIT "A"
CITY OF NEWPORT BEACH ENCROACHMENT PERMIT
(Please type or print legible. Press hard - makes 3 copies)
Permit # E.P. 7L e -Isj
[3] APPLICATION FOR: ❑ CURB CUT ❑ SEWER CONNECTION
(CHECK ONE) ❑ STREET EXCAVATION ❑ WATER CONNECTION
Amount Fee Paid $
' 0 4, X UNDERGROUND UTILITIES ❑ OTHER:
Receipt#
[2] ADDRESS OF WORK: '
MAcJRrHvAAVE, -e VON 16RMAN AVE,
[3] APPLICANT'S NAME METROM iFOIA ;AlDDRESS: j 68 7O EY t1liiEw A .:AREA CODE: 7 1 If
/Au
D /f
[3 - flK 5"--r-K.AA MlRAPA.-GA g06.39 &q0 -:3go
-:PHONE: _-
[4] OWNER'S NAME: METR0 MSOFA :ADDRESS: 16970 VALL15Y (f1EW Av&:'AREACODE: z
r7i
p n
r7WE NEiWdRK �c�VOGES 1N�_:r Jf Mlr?f)Di , -C- n 7_ 'ID638 :PHONE: (jC7-Q-3000V-
_ _.
[5] CONTRACTOR'S NAME: To LIE DETERMOMEO :ADDRESS: :Office Phone:
;Job Site Phone:
[6] APPLICANT HEREBY MAKES APPLICATION T0: :rN',STAL�- Fi&e-A QPTYC rOA1121111-
rN CirY5 Poet.IG 'ic of
(SEE ATTACHED PLANS)
SPECIAL COND TIONS OF APPROVAL RE UIRED BY CITY_:
C
JOEL GO -7 TOILN G--/ / ctt-hicP 11h EA 6�
-Water,
ovate and pothole existing City owned utilities (ie: ot lighting conduits) to verify locations prior to start of any work. Maintain a
one (1) foot clears ver "der fcisf gCity 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) 844-3011. 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. [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 seNnsure, or Certificate of Workers Compensation Insurance or a Certified Copy thereof.
Policy No.: Company: Expiration Date:
Dale: 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 Califomia. 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 an exempt fnxn hiring a contractor as I an the OWNER at the property and am personally performing all work within the Public nghtof-way. '
Date: Applicant
(signature)
12] HOLD HARMLESS STATEMENT
❑ 1 understand that I an locating minor encroachmen5 within the City dghtor-wayleasement. It is my responsibility as the property owner to maintain the
encroachments. I will be responsible for replacing the improvements it the Gty removes them for maintenance of uglibes or other public need; and I, the
property owner shall indemnity and hold the City harmless for any liability associated with the minor encroachments.
Date: Oxner 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)
141 * * * * * 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
UPROVAL REQUIRED
DATE 4IGNATURE - TITLE
�V—
e -/�� lot
#
/
tP
�yr'ti-
PERMIT ISSUED BY:
DATE ISSUED: EXPIRATION DATE OF PERMIT:
PERMIT DENIED:
White - Permit Pink - Temporary Office Copy Yellow - Applicant
I tS L)