TC2015-0021titit11
See below for Finance Revenue Codes
01' .4,
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: 4/1/2015
TION OF CONSTRUCTION(Street address or Description): WASHINGTON - RTTURN INTO ARCO
PURPOSE OF CONSTRUCTION: INSPECTION OF CABLE THROUGH MANHOLE.
DESCRIPTION OF CONSTRUCTION: VERIZON EMERGENCY PERMIT
DIMENSION OF INSTALLATION OR REMOVAL:
PROXIMATE TIME WHEN WORK WILL BEGIN: 3/12/2015 TIME OF COMPLETION: 4/2/2015
ESTIMATED CONSTRUCTION COST:._ (Including removal of all obstruction, materials, and debris, backfilling, compaction and placing
permanent resurfacing and/or replacing improvements)
AMEND ORIGINAL PERMIT TO INCLUDE EXTRA WORK AT HWY 111 AND WASHINGTON -SB SLOW LANE FOR FURTHER INSPECTION.
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. I
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicabl6 rules and regulati s the
to pay for any additional replacement necessary as the result of this work.
Signature of Applican$r Agent
VERIZON CALIFORNIA INC 18850 ORANGE STREET BLOOMINGTON, CA 92316
Name of Applicant (please print) Business Address Telephone No.
TOPS N BARRICADES INC 44-503 JACKSON STREET INDlO, CA 92201
.• (760)347-2111
Name of Contractor and Job Foreman Businesi Address Telephone No.
787664 • 103875
Contractor's License No. City Business License No.
SCOUSDALE INSURANCE CO CP52136336
Applicant's Insurance Company Policy Number
Finance Revenue Code
PERMIT INSPECTION
TRAFFIC CONTROL ONLY - 2-5 DAYS $580.00
TOTAL: $580.00
PERMIT NO: TC2015-0021
DATE ISSUED:
EXPIRATION DATE: LL3/ 1(0
BY:
INSPECTED BY*:
IT COMPLETION DATE*:
*If the work is covered by a Subdivision Improvement Agreement,
Subdivider shall request final acceptance of improvements from the
City Council.
4 ,
See below for Finance Revenue Codes
Twit 4
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: 3/31/2015
LOCATION OF CONSTRUCTION(Street address or Description): WASHINGTON - RTTURN INTO ARCO
PURPOSE OF CONSTRUCTION: INSPECTION OF CABLE THROUGH MANHOLE.
DESCRIPTION.OF CONSTRUCTION: VERIZON EMERGENCY PERMIT
DIMENSION OF INSTALLATION OR REMOVAL:
APPROXIMATE TIME WHEN WORK WILL BEGIN: 3/12/2015 TIME OF COMPLETION: 4/2/2015
ESTIMATED CONSTRUCTION COST: (Including removal of all obstruction, materials, and debris, backfilling, compaction and placing
permanent resurfacing and/or replacing improvements)
COMMENTS: AMEND ORIGINAL PERMIT TO INCLUDE ERA WORK AT HWY 111 AND WASHINGTON -SB SLOW LANE FOR FURTHER INSPECTION.
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 ttf8f and
to pay for any additional replacement necessary as the result of this work.
Signature of Applicant or Agent
VERIZON CALIFORNIA INC 18850 ORANGE STREET BLOOMINGTON, CA 92316 (909)879-2656
Name of Applicant (please print) Business Address S Telephone No.
TOPS N BARRICADES INC 44-503 JACKSON STREET INDlO, CA 92201 (760)347-2111
Name of Contractor and Job Foreman Business Address
787664
Contractor's License No.
SCOTTSDALE INSURANCE CO
Applicant's Insurance Company
Finance Revenue Code
PERMIT INSPECTION
TRAFFIC CONTROL ONLY - 2-5 DAYS $580.00
TOTAL: $580.00
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Telephone No.
103875
City Business License No.
CP52136336
Policy Number
PERMIT NO: TC2015-0021
DATE ISSUED:_
EXPIRATION DATE: #4
BY: 0,00~
WORK INSPECTED BY:
PERMIT COMPLETION DATE:
*lf 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
Date:
Tract No: Project
Vicinity: Wa5k fr) Et -/i)(1 tr -tb
Purpose of Construction (i.e.: =
e-
Grading, Mite Street, etc.)__________________
~Di5wrhD* V1 161 F ((ai'ko)e.
Description of Construction (i.e.: See Plan Set No. 01234)
Dimension of Installation or Removal:
Approximate Construction Start Date: 3/12 I
Approximate Construction Completion Date: j Vi 1 c
Estimated Construction Cost: $ 1
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: . Wed ,,e Phone Num"ç q_ O3 t( (
Name of ApplicantiOwñer:
Applicant Address: R3 - qj or,
Applicant Telephone Number: CZa ô.) ç? ' -_3 'ç.
Applicant E-mail Address:
Name of Contractor: IL)
contractor Address:
Contractor Telephone Number:
Contractor State License Number:
Contractor City Business License Number:
Contractor E-mail Address:
A COPY OF THE CURRENT INSURANCE CERTIFICATE MUST BE PROVIDED 4
Applicant or Contractor General Liability Insurance Company:
Applicant or Contractor General Liability Insurance Policy Number:
Office Use Only:
Inspection Fee:
Permit Fee:
As-Built
Deposit:
Dust Control
Deposit:
Credit
Amount:
0 01
TOTALFEEDUE: 7O
- Forms & AoDllcatlonsADDIication
Office Use Only: I
Assigned Permit Number:
Approval Date: J
Expiration
Date:
Issue
Date:
Administrative Authority:
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77- 3t01O
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