HomeMy WebLinkAboutN2000-0360Shm,,J\ d!,VI s TPA 7-99 EP Form.xle
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EXHIBIT"A
CITY OF NEWPORT BEACH ENCROACHMENT PERMI
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[1] APPLICATION FOR: ❑ CURB CUT ❑ SewER c o
(CHECK ONE) ❑ STREET EXCAVATION ❑ WATER CONNECTION
Amount Fee Paid $ 32
❑ UNDERGROUND UTILITIES ❑ ER:
Receipt# 1. &I
[2] ADDRESS OF WORK: 3 3 >} (a \/ I A L 1, CD
[3] APPLICANT'S NAME :ADDRESS: t yl; 34q :AREA CODE: :11 L[ —
C TGp k -JC 53-� N'l-W?ORI `C!144 Z 0)0 ;PHONE: 3;j-.1 -_!-_—
[4] OWNER'S NAME: :ADDRESS: :AREA CODE: C-0lllw f I
SfrM :PHONE:.
[S] CONTRACTOR'S NAME: :ADDRESS: :Office Phone:
5 Aro�C :Job Site Phone:
[6] APPLICANT HEREBY MAKES APPLICATION T0: , 7-y2m G C V A 6 v T7 2
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(SEE ATTACHED PLANS)
SPECIAL CONDITIONS OF APPROVAL REQUIRED BY CITY: _ rem t� w su w�re�o
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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 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. [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 self -insure, or Certificate of Workers Compensation Insurance or a Certified Copy thereof.
Policy No.: Company: Expiration Date:
Date: 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
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)
121 HOLD HARMLESS STATEMENT
❑ 1 understand that I am Iocaling 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 if the City removes them for maintenance of utilities 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: 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 understands said terms co di6onsand"i at he rees to abide by them.
OWNERS OR AUTHORIZED AGENTS SIGNATURE (DATE)
14] * * * * * TREES WITHIN THE CITY'S RIGHT-OF-WAY * * * * *
NO TREES WITHIN THE Crr rS 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 - TYRE
PERMIT ISSUED BY:
DATE ISSUED: EXPIRATION DATE OF PERMIT:
PERMIT DENIED:
White - Permit Pink - Temporary Office Copy Yellow - Applicant
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