CIP2018-0004See below for Finance Revenue Codes
-EMcfthtDESEkT--.--
CIP
PUBLIC WORKS CONSTRUCTION
For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains and other like public works
improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS.
DATE: 8/2/2018 S
LOCATION OF CONSTRUCTION(Street address or Description): ZONE 2 - SEE APPROVED PLANS
PURPOSE OF CONSTRUCTION: SLURRY SEAL AND STRIPING IMPROVEMENTS
DESCRIPTION OF CONSTRUCTION: CIP 2017-27. FY2017/2018 PAVEMENT MANAGEMENT PLAN
DIMENSION OF INSTALLATION OR REMOVAL:
APPROXIMATE TIME WHEN WORK WILL BEGIN: 8/9/2018 TIME OF COMPLETION: 10/8/2018
ESTIMATED CONSTRUCTION COST: S696.751.00 (Including removal of all obstruction, materials, and debris, backfilling, compaction and
placing permanent resurfacing and/or replacing improvements)
COMMENTS: SEE PROJECT CONTRACT AND SPECIFICATIONS FOR CIP 2017-27 FOR PERMIT CONDITIONS
In consideration of the granting of this permit, the applicant hereby agrees to:
Indemnify, -defend and save the City, its authorized agents, officers, representatives and employees, harmless from and against any and all
penalties, liabilities or loss resulting from claims or court action and arising out of any accident, loss or damage to persons or property
happening or occurring as a proximate result of any work undertaken under the permit granted pursuant to this application.
Notify the Administrative Authority at least twenty-four (24) hours in advance of the time when work will be started at (760) 777-7097. To
submit an inspection request, leave a.message on the Inspection Request Hotline at (760) 777-7097 prior to 1:30 P.M. at least twenty-four (24)
hours prior to the anticipated inspection.
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules and regulations of the City of and to
pay for any additional replacement necessary as the result of this work.
Signature0of Applicant or Agent
AMERICAN ASPHALT SOUTH INC - JEFF
PETTY 14436 SANTA ANA AVE FONTANA, CA 92337 . (909)427-8276
Name of Applicant (please print) Business Address S Telephone No.
AMERICAN ASPHALT SOUTH INC 14436 SANTA ANA AVE FONTANA, CA 92337 (909)427-8276
Name of Contractor and Job Foreman Business Address• Telephone No.
784969 LIC-10009
Contractor's License No. City Business License No.
FINANCIAL PACIFIC INS COMPANY 60423382
Applicant's Insurance Company Policy Number
Finance Revenue Code
TOTAL: $0.00
PERMIT NO: ClP2018-0004
DATE ISSUED:
EXPIRATION DATE:
WORK INSPECTED 8Y:
PERMIT COMPLETION DATE*:
*If the work is covered by a Subdivision Improvement Agreement,
Subdivider shall request final acceptance of improvements from the
City Council. S
PUBLIC WORKS DEPARTMENT
APPLICATION FOR PERMIT
Date:
Tract No:Project Name: P? Zol1/I Prniji tw-r P1irJ
Vicinity: LoiJe 2..
Purpose of Construction (i.e.: Rough Gradin , Offsite Street, etc.) SLO(ti.J ta9
CA4d:
Description of Coion (i.e.: See Plan SetNo. Ol234 5LIJIY) Sri.t nstruct
VA.lDoS uote)
Dimension of Installation or Removal:
Approximate Construction. Start Date: 11- /IS
Approximate Construction Completion Date: 1 0 — —
t Estimated Construction Cost: $ (g 1(p C) . .
Estimated Construction Cost shall include the removal olall obstructions. Materials, and debris, back-filling compaction and
placing permanent resurfacing and or replacing improvements
Contact Name: J€-4 Yi4 Phone Number: 'WI LtZ.7 ZZ7lo
Name of Applicant/Owner: "Amer,an Asç4i2/,- 4)rft
Applicant Address: 143(a S&MA erA AJt *u j rAl CtM7
Applicant Telephone Number: Mi- 42.7-971(,p
Applicant E-mail Address: LQ1CO
Name of Contractor: inCC.O( J)c,9ktk- 5oO+i INC..
Contractor Address: 1'443c otJ#A_A.i1 Ai 1-c'nlana,CA 9233
Contractor Telephone Number: q O-1 V7-2.7&,
Contractor State License Number: 1 4(09
Contractor City Business License Number: 00 ?OOO
Contractor E-mail Address: .ky € aertccq,cØyjl 4-50u4- COY .'l
A COPY OF THE CURRENT INSURANCE CERTIFICATE MUST BE PROVIDED-4
Applicant or Contracto,Qçneral Liability Insurance Company:
V-i on Pew 0,cqk
Applicant or Contractor General Liabi
hD42.3
Office Use Only:
Inspection Fee
PermiFee 40
As-Built
Deposit.
Dust Control
Deposit
Credit
Amount
TOTAL FEE DUE
Insurance Policy Number:
pmce Use Only:
Assigned Permit Numb
Approval Date
Espirutión
Date
Issue
Date
Administrative Authority