The URL can be used to link to this page

Home My WebLink AboutN2001-0220sysoaaa.xu (' = EXHIIBIT "A' CITY OF NEWPORT BEACH ENCROACHMENT ERMI1` ` FOR OFFICE USE ONLY (Please type or print. Press hard - make 3 copies) Permit #E.P. -Load--L7- Z(CHECK (1) APPLICATION FOR: ❑ CURBCUT ❑ SEWER C NN (CHECK ONE) 1E] STREET EXCAVATION ❑ WATER CONNECTION Amount Fee Paid $ 00 1(7 UNDERGROUND UTILITIES ❑ OTHE Receipt G (2) ADDRESS OF WORK EAST BAY AVE W R &AWiJil- (3) APPLICANTS NAME :ADDRESS: ePHbf4fcr�, SOUTHERN CALIFORNIA GAS CO P.O. BOX 3334 ANAHEIM,CA 92800 (714W-3066 (4) OWNERSNAME :ADDRESS: :PHONE-- PHONE(5) (5)CONTRACTOR'SNAME -rlepp 'ADDRESS: ;Dittos Phone: ;Job Site Phone: (6) APPLICANT HEREBY MAKES APPLICATION TO: REPLACE 12 YEAR OLD 4" PE -MAIN IN EAST BAY AVE. BEGINNING APPROX 5' W/WPL OF WASHINGTON AVE. HEADING EASTERLY TO A POINT ENDING APPROX 20' E/EPL OF WASHINGTON AVE OPEN TRENCH CONCRETE CUT Amy tic r ` s se -r u P P4:--tt pfE WA'ru k_ (SEE ATTACHED PLANS) SPECIAL CONDITIONS OF APPROVAL REQUIRED BY CITY: Q p -to -rate and pothole ex's ' City owned utilities ('e: water, sewer, or street lighting conduits) to verify locations prior to start of any work. Maintain a one (1) foot clear v o e 'stin C' ned 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 requ ed, 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 Worker's Compensation Insurance ora Certified Copy thereof. Policy No.: Company: Expiration Date: ❑ Certified Copy hereby furnished Date: Applicant: (signature) (10) CERTIFICATE OF EXEMPTION W Ili �t�F-� (Section 3800 Labor Code) ( 1 ❑ 1 certify that in the performance of the work for which this permit is issued, I shall not employ -(�'J IF Y to the Worker's Compensation Laws of California. I V �E )}r � jXy(\� . If, after signing this certificate I become subject to the Worker's Compensation provisions of t -rte'1�F r ' tTJ Section 3700 or this permit shall be deemed revoked. VVI�D` .-,I-f II Date: 6/8/01 Applicant: STUART HAFER ( T �� , )r (signature) - t"oti . �I'1�'T_ _ mllE.i (11) CONTRACTOR LICENSE EXEMPTIO Y�(01�IL � I— ❑ 1 am exempt from hiring a Contractor as I am the OWNER of the property and am personally ` nk,51> P 60 3�1 ',,I4e Date: Applicant:' (signature) (12) HOLD HARMLESS STATEMENT ❑ I understand that I am locating minor encroachments within the City right-of-way/easement. It V12D0 f _ 0212-0 encroachments. I will be responsible for replacing the improvements if the City removes them y)ZpO t - C)42jo 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 (714) 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 and conditions and that he agrees ti ija by them. STUART HAFER 6/8/01 OWNERS OR AUTHORIZED AGENTS SIGNOI&RE (DATE) SPACE BELOW THIS LINE FOR OFFICE USE DEPARTMENT APPROVAL REQUIRED DATE SIGNATURE -TITLE Q -C L Us vlit -'CV-A r -Fl S 25 O A"VC_ PERMIT ISSUED BY: DATE ISSUED: EXPIRATION DATE OF PERMIT: PERMIT DENIED: While - Permit Pink - Temporary Office Copy Yellow - Applicant lu,L nw.a��,ee.awrwnr:w 3-01 Fmmak EXHIBIT -A- CITY OF NEWPORT BEACH ENCROACHMENT PERMIT (Please type or print legible. Press hard - makes 3 copies) R .. � 'f�� Z Amount Fee Paid S, 36 [1 ❑ CURB CUT ❑ SEWER CON NE I (CHECK ONE) ❑ STREET EXCAVATION ❑ WATER CONNECTION ❑ UNDERGROUND UTILITIES ❑ OTHER Receipt# orf/!P [2] ADDRESS OF WORK: £ (1 I 1 [3] APPLICANTS NAME ;ADDRESS: :AREA CODE: k6 ( [PHONE: —7 �oZS [4] OWNERS NAME: :ADDRESS: /r :AREA CODE: :PHONE: [5] CONTRACTOR'S NAME: ;ADDRESS: I ;Office Phone: :Job Site Phone: APPLICANT HEREBY MAKES APPLICATION TO: �r AC SPECIAL CONDITIONS OF APPROVAL REQUIRED BY CITY: U 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 -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 addition when a sewer cleanout is required, V.C.P., or P.V.C. SOR35 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 800-422-4133 [7] Contractor's City License No. BT- [81 State License No. Class [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: Date: Applicant (signature) [10] CERTIFICATE OF EXEMPTION (Section3800 Labor Code) certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so a to become subject to the Workers compensation laws of California. If, after signing this certificate I become sub' to the provisions the State Labor Code, I must comply with the provisions of Section 3700 or this ermit shall be deemed revoked. Date:L0.-vwpplicant. ' (Signature) [71] CONTRACTOR LICENSEE EM ❑ 1 am exempt from hiring a Contractor as I am the OWNER of the property an personally performing all work within the Public right-of-way. Date: Signature: [12] HOLD HARMLESS STATEMENT I understand that I am locating minor encroachments within the City right-of-wayleasem . It is my responsibil' as the prope owner to maintain the encroachments. I will be responsible for replacing the improvements if re eS main a utilities or other public need; and I, the property owner shall indemnify and hold the City harmless f i S a c Date: (2 a C1 1 Owner Signat [13] 24 HOUR ADVANCE NOTICE IS REQUIRED FOR ALL INSPECTIONS- CALL 949 6443311 The terms and conditions of this permit are printed on both sides of this form. Applicant hereby acknowledges he/she has read and understands said terms and conditions and he/she agrees to abide by them. No work related to this encroachment permit shell be performed until this permit has been issued.'. -' Owner or Authorized Agent Signature Date NO TREES OR LANDSCAPING 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 PERMIT ISSUED BY: DATE ISSUED: PERMIT DENIED: White - Permit Pink - Temporary Office Copy Yellow - Applicant c i Requested Inspect Date: Tuesday, February 25, 2003 Assigned To: zzzzzzzzzzz* Inspection Type: ENCROACH Inspection Area: PW Site Address: 617 BEGONIA AVE NB AIPID Information Activity: N2001-0223 Type: ENCROACH Sub Type: NEW Const Type: Occupancy: Use: Description: INSTALL CONCRETE/STONE 4.5 X 5' PAD IN PARKWAY Reauested Insoection(s Item: 10250 FINAL - PW Requestor: WEBUSER Comments: ANY -FINAL Assigned To: 77777777777* Action: Time Exp: Status: APPROVED Insp Area: PW Requested Time: 12:00 AM Phone: Entered By: WEBUSER WB Inspector: ; ji/ Date: ,'c aZ S� Time: A: PM Comments: our REFT131 Run Id: 570