HomeMy WebLinkAboutN2000-0414U
RIFOW XIS
EXHIIBIT "A"
CITY OF NEWPORT BEACH ENCROACHMENT PERMIT
FOR OFFICE USE ONLY
(Please type or print. Press hard - make 3 copies)
Permit If E.P. N'Z O 60 —4,- �y.
(1) APPLICATION FOR: ❑CURB CUT ❑ SEWER CONNECTION
(CHECK ONE) ar STREET EXCAVATION ❑ WATER CONNECTION
Amount Fee Paid $ k'2- 1 _ 7, S
❑ UNDERGROUND UTILITIES ❑ OTHER:
Receipt# 7 5? 2 - —7 47
(2) ADDRESS OF WORK. Z I D 1 NIU' StAKy LANG
(3) APPLICANT'SNAME 'ADDRESS:
A7vu,32 AA UAa-Sory Ell
'PHONE:
`l`f9 y533ov
(4) OWNER'S NAME :ADDRESS:
:PHONE
S Amc-7
(5) CONTRACTORS NAME: €ADDRESS: WWUUIU L6L6 U L6UU:Office
Phone:
_
:Job Site Phone:
(6) APPLICANT HEREBY MAKES APPLICATION TO:
C (Y_!J 114771elgE 7--c-ATE
SI ZC L1Y w( ✓L S T9 — O�-L.- To T o
(SEE ATTACHED PLANS)
SPECIAL CONDITIONS OF APPROVAL REQUIRED BY CITY: p " "
E) %--1, VL- 0 L- C. 0 t -o C' P. c l C E c C= FL o In T
(2Z) 94 0
❑ Locate and pothole existing City owned utilities (is: 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 Cfty 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 (714) 644-3011. In addition, 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 7-800-422-4133
(7) CONTRACTOR'S CITY BUSINESS LICENSE NO. (8) STATE LICENSE NO. ori"
(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.
Policy No.: Company: Expiration Date:
❑ Certified Copy hereby furnished
Date: Applicant:
(signature)
(10) CERTIFICATE OF EXEMPTION
(Section 3800 Labor Code)
u I certify that in the performance of the work for which this permit is'ssued, I shall not employ any person in any manner so as to become subject
to the Worker's Compensation Laws of California.
#, after signing this certificate I become su ' to the Worker' Compensation prov' ' ns of the State Labor Code, I must comply with the provisions of
Section 3700 or this permit shall be d med re oked.
Date: Applica zz
(signature)
1) C TRACTOR LICENSE EXEMPTION
❑ lam exempt from hiring a Contractor as I am the OWNER of the property and am personally performing all work within the Public rightof-way.
Date: Applicant:
(signature)
(12) HOLD HARMLESS STATEMENT
❑ 1 understand that I am locating minor encroachments within the City right-of-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 I, 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 _74) 644-3311
The t ms an conditio f this permit are pri on both sides of this form. Applicant hereby acknowledges that he has read
an ndersta said terms cond'Aions and that agrees to abide by them.
khtz
OWN SA ORI AGENTS SIGNATURE (DATE)
SPACE BELOW THIS LINE FOR OFFICE USE
DEPARTMENT APPROVAL REQUIRED DATE SIGNATURE -TITLE
PERMIT ISSUED BY: �
DATE ISSUED: 10 Z 6,_z- o EXPIRATION DATE OF PERMIT:
PERMIT DENIED:
While - Permit Pink -Temporary Office Copy Yellow - Applicant