TC2014-1034Ct / See below for Finance Revenue Codes
, 1 ENCROACHMENT PERMIT
OF fl'"
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.
PATE: 10/30/2014
LOCATION OF CONSTRUCTION(Street address or Description): NORTH COVE AREA
PURPOSE OF CONSTRUCTION: SLURRY SEAL FOR CIP 2012-07A
DESCRIPTION OF CONSTRUCTION: CIP 2012-07A SLURRY SEAL
DIMENSION OF INSTALLATION OR REMOVAL:SEE PLANS
APPROXIMATE TIME WHEN WORK WILL BEGIN: 9/29/2014 TIME OF COMPLETION: 11/17/2014
ESTIMATED CONSTRUCTION COST: (Including removal of all obstruction, materials, and debris, backfilling, compaction and placing
permanent resurfacing and/or replacing improvements)
-
COMMENTS: SEE SPEC BOOK FOR 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 inadvance 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.j2
.
or Agent
JEFF PETTY - AMERICAN ASPHALT P.O. BOX 310036 FONTAN4A CA 92331 ." (909)427-8276
Name of Applicant (please print) Business Address Telephone No.
AMERICAN ASPHALT SOUTH INC P.O. BOX 310036 FONTANA, CA 92331 (909)427-8276
Name of Contractor and Job Foreman Business Address Telephone No.
784969 10009
Contractor's License No. City Business License No
FINANCIAL PACIFIC INS COMPANY
Applicant's Insurance Company
Finance Revenue Code
TOTAL: $0.00
60423382
Policy Number
PERMIT NO: TC2014-1034
DATE ISSUED: 12131//V
EXPON DATE:L/31/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.
C&r o 4u14i,
7 PUBLIC WORKS DEPARTMENT
APPLICATION FOR PERMIT
Date:
Tract No: _Project Name: Pcoc t40. ;90 1'7— —0M
Vicinity: 4OT4 Co e. AE
Purpose of Construction (i.e.: Rough Grading, Offsite Street, etc.) 'SLOtZ12AJ SE A L
Description of Construction (i.e.: See Plan Set No. 01234)
Dimension of Installation or Removal:
Approximate Construction Start Date: Ct_ l"t 4
Approximate Construction Completion Date: kN - ti I'-
Estimated Construction Cost: $ 33t5 1010
Estimated Construction Cost shall include the removal of all obstructions, materials, and debris, back-filling, compaction and
placing permanent resurfacing and or replacing improvements
Contact Name: 3ecc P€L, Phone Number: jOi - 421 g76
Name of Applicant/Owner: rc- Astio.tc 56crr4 tr.-.
Applicant Address: t-H A Ait c>'I4A.A) CA ?'1
Applicant Telephone Number: C1 00% a..f,)
— Z 2-1(a
Applicant E-mail Address: ie4' €. Ame c- 1 CXXno Soj4k. Cpvt
Name of Contractor: ,4y1C.(lCc( Asç*ut+ Gooky, t"4 C...
Contractor Address: F.C. Io.,< 3 0o30 RnAJA c iZ3I
Contractor Telephone Number: Cl C -
Contractor State License Number:
Contractor City Business License Number: J 0 DO q
Contractor E-mail Address: jçç P @ com
A COPY OF THE CURRENT INSURANCE CERTIFICATE MUST BE PROVIDED
Applicant _or Contractor Genera).Liability Insurance Company:
Applicant or Contractor General Liability Insurance Policy Nuinber: "
(19 042338-a
Office Use Only: Office Use Only:
Inspection Fee:
—
Assigned Permit Number: _77 f(4s
1034
Permit Fee: Approval Date:
As-Built Expiration
Deposit: Date:___________________________________________
Dust Control Issue
Deposit: Date:
Credit
Amount: Administrative Authority:
TOTAL FEE DUE:
I In,jI( :PIQ,-kl,cyc - I-rlrrnc K. nnhIr'?,rSnc A I,Irn frs JrvS? .73— 1-
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