STR2016-0004See below for Finance Revenue Codes
ENCROACHMENT PERMIT
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: 6/10/2016
LOCATION OF CONSTRUCTION(Street address or Description): EISENHOWER BTW AVE FERNANDO & COACHELLA
PURPOSE OF CONSTRUCTION: PAVEMENT REHAB
DESCRIPTION OF CONSTRUCTION: CIP2015-01 EISENHOWER DR PAVEMENT STABILIZATION IMP PROJECT
DIMENSION OF INSTALLATION OR REMOVAL: -
APPROXIMATE TIME WHEN WORK WILL BEGIN: 7/11/2016 TIME OF COMPLETION: 8/11/2016
ESTIMATED CONSTRUCTION COST: S350.000.00 (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 2015-01 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 applicabl Arulesd reguIos of the City of and
to pay for any additional replacement necessary as the result of this work. ) 7/ j ii 4 (\
of Abpllcant or
EAGLELIFT -CLIFF FRAZAO 10410 TRADEMARK STREET RANCHO CUCAMONGA, CA 91730 '-f909)472-655
Name of Applicant (please print) Business Address Telephone No.
EAGLELIFT INC . 10410 TRADEMARK STREET RANCHO CUCAMONGA, CA 91730 (909)980-6222'
Name of Contractor and Job Foreman Business Address Telephone No.
778157 LIC-0101696
Contractor's License No. City Business License No.
IRONSHORE SPECIALTY INS. CO.
Applicant's Insurance Company
Finance Revenue Code
TOTAL: $0.00
AGSOO76SO1
Policy Number
PERMIT NO: STR2016-0004
DATE ISSUED:
EXPIRAToN I
WORK INSPECTED BY*:
PERMIT COMPLETION DATE*:
*If the work is covered by a Subdivision Improvement Agreement,
Subdivider shall request final acceptance of improvements from the
City Council..
PUBLIC WORKS DEPARTMENT
APPLICATION FOR PERMIT
Tract No: A Project Name:
VI. .
Purposeof Construction (i.e. Rough Grading, Offsite Street,
Description of Construction (i.e.: See Plan Set No. .0 1234
L.
)
1 .. ' 17'
Approximate Construction Start Date: ?&
Approximate Construction Completion Date:
Estimated Construction Cost:. $E3' . •,:!.
•. ....
?. ...
Estimated Construction Cost:shall include the removal of all cfbstruciions, materials, and debris, back-filling, compaction and
placing permanent resurfacing and or replacing improvements •
Contact Name: [CL . I TO Phone Nurnber:L LV°
Name of Applicant/Owner r L .Le\f"7O/L .
Applicant Address [(b't b Tr.,cQ.4MAJt%C.. ..4&k46 cio .,~A]
Applicant Telephone Number: .
Applicant E-mail Address:E
Name of Contractor F
Contractor Address
Contractor Telephone Number
Contractor State License Number:
ContractofCit' Business License Number:
Contractor E-mail
ACOPY OF THE CURRENT INSU ANCE CERTIFICATE MUST BE PROVIDED
Applicant or Contractor General Liability Insurance _Company:
Applicant or Contractor General Libility Insudnce Policy Number:
Office Use Only:. • . • Office Use Only: •
Inspection Fee: • . . . • • . . . • Assigned Permit Number-ft 2o16
Permit Fee: . • Approval Date:
As-Built • . . • .. Expiration . •.
Deposit: . Date:___________________________________________
Dust Control •. . • Issue .
Deposit:. •.•• • Date: ••
Credit . . •
Amount: Adminiâtrative Authority:
TOTAL FEE DUE: _.••.I I
UnveluflecKllsts 7 i-orms & Mpp7lcaflonslApplication for i-'ermit poste