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Home My WebLink AboutN2001-0043shareMEn.aach\hksten\EDi 7-99 EP Formals PY14TRTT"A" CITY OF NEWPORT BEACH ENCROACHMENT PERMIT -.;a (Please type or print legible. Press hard - makes 3 copies) [1] APPLICATION FOR: ❑ CURB CUT 10 rr eI A�EJ.p.d I —0 S ONE) ❑ STREET EXCAVATION WE L(CHECK A o e aid$0R S'9-?� UNDERGROUND UTILITIESReceipt# 30'/J41-? [2] ADDRESS OF WORK: 8.5-1 Iflemomr la'k-'P'e , [3] APPLICANT'S NAME :ADDRESS: ;AREA CODE: 714- -Z) ;?C5 71,t5- :PHONE: 103.?-33?Z /173/lil [4] OWNER'S NAME: �ETG L' nt E/Z ;ADDRESS:--rXV1NCr01# TZ4 �� :AREA CODEg4-e7 L13L.V �.l "14' ` 5 P/ 5GO 1/�h)/ 14 D 7*,9t,--- I - -- -:PHONE: Phone: 7/4 [5] CONTRACTOR'S NAME: ;ADDRESS:94/8 ,Office C US ;z$�i/ EAoRoNadD A. ::Job Site Phone: 63-�Z —3322 [6] APPLICANT HEREBY MAKES APPLICATION TO: /r/ rr is .d w A/uueC >e v pti- iv Oil (SEE ATTACHED PLANS)` SPECIAL CONDITIONS OF APPROVAL REQUIRED BY CITY: N _ C-TI6ir% SL`L ❑ 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 " 1 Kc' -57,euw<n i 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. O d 7 [B] STATE LICENSE NO [9] WORKERS COMPENSATION INSURANCE CERTIFICATE OF INSURANCE (Section 3800 Labor Code) ❑ I 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.: 1476,4,5 7 Company:_ 577-eT-FOAl,b Expiration Datl A �� Date:� / 61 Applicant J/-— (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 pedorming all work within the Public right-of-way, Dale: 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 urllities or other public need; and I, the property owner shall indemnify and hold the Gty harmless for any liability associated with the minor encroachments. Date: Owner 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 'terms and conditions and that he agrees to all a by them. O(NNERS OR AUTHORIZED AGENTS SIGNATURE (DATE) 14] * * * * * TREES WITHIN THE CITY'S RIGHT-OF-WAY'* NO TREES WITHIN THE CRY'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 SIGNATURE - TITLE PERMIT ISSUED BY: DATE ISSUED: 2--1� m/ EXPIRATION DATE OF PERMIT: HERMIT DENIED: Re - Permit Pink - Temporary Office Copy Yellow - Applicant -A Shams\Encro \Masters\EPA 799 EP Formals EXHIBIT "A" CITY OF NEWPORT BEACH ENCROACHMENT PERMIT (Please type or print legible. Press hard - makes 3 copies) Permit#E.P. [i] APPLICATION FOR: ❑ CURB CUT ❑ SEWER CONNECTION (CHECK ONE) ❑ STREET EXCAVATION ❑ WATER CONNECTION Amount Fee Paid $_ 4 BS -9e 1G 1:1 UNDERGROUND UTILITIES ❑ OTHER: Receipt#'9r&191945 [2] ADDRESS OF WORK: �, 9ia„ �v `Sr,�r O -L_ [3] APPLICANTS NAME % :ADDRESS: ` :AREA CODES J/ js., [Gt : _V;P/4 GAO^Yst-r4-QI��%Z�1/�l%t :PHONE: "-LO �]. .S -- [4] OWNER'S NAME: 7�$LUIIIE,- :ADDRESS: ¢3 4' S�Co(/-e lJ/ /00 ;AREA CODE: 449 c -7�X ILS c0 'Crtl l / ib---jeVI t/c/ 69 �IaZ,.- ,PHONE: %��' a�4�a'Z• __ _ [5] CONTRACTOR'S NAME: 'ADDRESS:/�1 :Office Phone: 7/ V fi 7 I P,0,1 OU. ,O 6 j • ob Site Phone: ^3 '4- [6 APPLICANT HEREBY AKES APPLICATION TO: n s&&g p O �' (aS �.N 2 AoJST+r L� 3•J AA. S. M r -e— b 6 iL a 1 O r-.3 _11;4-r 'OCJ.L Po `•Jae aa�(SEE ATTACHED PLANS) SPECIAL CONDITIONS OF APPROVAL REQUIRED BY CITY: (L� - c„�S >QJ C-ni--1.tel Va 1 -I -F Q-toprti �2 t c%J L r v n c� +F�rJv 2f Locate and pothole existing bty owned utilities (ie: water, sewer, or street lighting conduits) to verify locations prior to start of any work. Maintain a flZ 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 43 ti please conlactl l MI I i� �Sk N 6(Corz I of the Utilities Department, 48 hours prior to staff of any work at (949) 644-3011. In add CZU I 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** J CONTACT "UNDERGROUND SERVICE ALERT" AT LEAST 48 HOURS IN ADVANCE 1 OF ANY EXCAVATION AT 1-800-422-4133 [7] CONTRACTOR'S CITY BUSINESS LICENSE NO. 14 A 0 [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 Worker's Compensation Insurance or a Certified Copy thereof. �% Policy No.: yr r7 Company: 7til nd Expiration Date: -'_/7Z O Date: L' 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 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 hiding a Contractor as I am the OWNER of the property and am personally performing all work within the Public fight -0f -way. pate; 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 g the City removes Nem 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: 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 aconditions and that he agrees to abide by th S�^ • 1 rW OWNE6 OR AUTH'OkIZED AGENTS SIGNATURE v �(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 SIGNATURE - TITLE i rryII �-1�-�'%..Ql. a,-ef'D1I c.'L oa -oi-off - PERMIT ISSUED BY: DATE ISSUED: ( EXPIRATION DATE OF PERMIT: PERMIT DENIED: White - Permit Pink - Temporary Office Copy Yellow -Applicant h� �hu,s cle:lw/r Xsyr� �