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CITY OF NEWPORT BEACH ENCROACHMENT PERMIT
(Please type or print legible. Press hard - makes 3 copies)
Permit # E.P. N ZOOO— 349
[1] APPLICATION FOR: ❑ CURB CUT ❑ SEWER CONNECTION
(CHECK ONE) ❑ STREET EXCAVATION Cl WATER CONNECTION
Amount Fee Paid $ S E c C--(3
(a&+ '0 r1�
0 UNDERGROUND UTILITIES OTHER: j!,L6ereeaa(,y
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Receipt#
[2] ADDRESS OF WORK: 0 G P C
[3] APPLICANT'S NAMEY -q�� J ;AREA CODE: 0'
�� :ADDRESS:;
� VIAIV-pt�� (JG'W'A.-r,( PHONE: 6 5d--0 7,E3
[4] OWNER'SRAME: ',ADDRESS: 3 7 W �. I QO�, TPT.9-AREA CODE: C37 0�
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COr _i 7,lp mV1. CQ/ (:�4 .PHONE:
[S] CONTRACTOR'S NAME: :ADDRESS: :Office Phone:7111) A2.6 —174 J
Phone:(-71z/)A2.6
:Job Site Phone:
[6] APPLICANT HEREBY MA'fS71APPLICATION T0: tw\ ✓vt
Vi
(SEE ATTACHED PLANS)
SPECIAL CONDITIONS OF APPROVAL REQUIRED BY CITY: T/Lf�FrCG /�T/LOL /�E2
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❑ 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
OF ANY EXCAVATION AT 1-800-422-4133
[7] CONTRACTOR'S CITY BUSINESS LICENSE NO. 'T Z.oc 5'`1Y [8] STATE LICENSE NO.
[9] WORKERS COMPENSATION INSURANCE
CERTIFICATE OF INSURANCE
(Section 3800 Labor Code)
❑ 1 certify that I have aC,e Certificate of consent to self -insure, or Certificate of Worker's Compensation Insurance or a Certified Copy thereof.
Policy No.: 1, fl''1-"/ 0q 3 ^ 190 Compan/y:' (n I~" 57 �j� k(;- Expiration Dater
Date: Applicant: JC1064
(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
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 an the OWNER of the property and am personally pedorming all work within the Public nghtof-way.
Dale: Applicant:
(signature)
[12] HOLD HARMLESS STATEMENT
❑ 1 understand that I an localing minor encroachments within the City rightof-wayleasement. It is my responsibility as the property owner to maintain the
mcmachrnents. I will be responsible for replacing the improvements Ifthe City removes them for maintenance of utilifies or other public need: and I, the
property owner shall indemnify and hold the City harmless for aq 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
\� and and lands temrs; and condition/s;Bnd 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 I SIGNATURE - TITLE
5-6
PERMIT ISSUED BY
DATE ISSUED: EXPIRATION DATE OF PERMIT:
PERMIT DENIED:
White - Permit Pink - Temporary Office Copy Yellow - Applicant