HomeMy WebLinkAboutN2000-0369Shered\E ch\Ma m\EPA 7.99 EP Form.xls
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EXHIBIT"A"
CI Y OF NEWPORT BEACH ENCROACHMENT P
P
(Please type or print legible. Press hard -makes 3 copies)
Permit # E.P. to z000 _ 3 6 5)
[S] APPLICATION FOR: ❑ CURB CUT ❑ SEWER CONNECTION
(CHECK ONE) ❑ STREET EXCAVATION ❑ WATER CONNECTION
Amount Fee Paid $
❑ UNDERGROUND UTILITIES ❑ OTHER: SLJrkn-y
Receipt#
[2] ADDRESS OF WORK:
[3] APPLICANT'S NAME :ADDRESS: :AREA CODE:
:PHONE:
[4] OWNER'S NAME:
G� /� ;ADDRESS: � 3 C � %Yt �� r� ;AREA CODE �/ Ct
/
:PHONE:
[S] CO
�R14 ]E 'y/7 _
C N dl ADDRESS 9 3 3 L G w 1.2/✓ G Office Phone: 7 / c/l 6'3.,)
i�r" :Job Site Phone:
[6] APPLICANT HEREBY MAKES APPLICATION TO: 2 J k
A rr T
(SEE ATTACHED PLANS)
SPECIAL CONDITIONS OF APPROVAL REQUIRED BY CITY: F -VL C— C> r -:i —r-tL-0 CrL
W FST A
❑ 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. 7
[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 Worker's Compensation Insurance or a Certified Copy thereof.
� 19 O G `F B`�i Pi r6t�
Policy No.: �LW 4 ` Company: Expiration Date: /
Date: g" % �� Applicant -
ignature)
30] 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, 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)
[31] CONTRACTOR LICENSE EXEMPTION
❑ 1 am exempt from hiring a Contactor as I am the OWNER of the property and am personally performing all work within the Public right-of-way.
Dawl— I S:9 Applicant
(signature)
[12] HOLD HARMLESS STATEMENT
❑ 1 understand frail am locating minor encroachments within the City right-of-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 Nem for maintenance of utilities or other public need: and 1, the
props owner shall indem dhold the City as for any 'lityassociatedwith the minor encroachments.
Date _ ryrffier 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 understagd rfns and Gond"os (d that a abide by them. p `�
OWNERS OR AUTHORIZED NTS 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
APPROVAL REQUIRED DATE SIGNATURE - TITLE
� /D�E�P-ARTMENT
PERMIT ISSUED BY:-
EX
DATE ISSUED: i — Z PIRATION DATE OF PERMIT:
PERMIT DENIED:
White - Permit Pink - Temporary Office Copy Yellow - Applicant
CITY ,OF NEWPORT BEACH
PUBLIC WORKS DEPARTMENT
2OF2
SKETCH FOR ENCROACHMENT PERMIT NO. EP- t-� 20®D — _� o
LEGEND:
0 = TREE Job Address
$ = POWER POLE Owner
A= SEWER CLEANOUT
Telephone No,
Q = WATER METER BOX
s
Center0ne of
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pp cant's Signature ate
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 shalt be done according to City Specifications and is subject to City Inspection.