TC2015-0057-
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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: 8/25/2015
LOCATION OF CONSTRUCTION (Street address or Description): VARIOUS STREETS
PURPOSE OF CONSTRUCTION: CIP 2012-07C - SLURRY SEAL
DESCRIPTION OF CONSTRUCTION: FY 2015/16 SLURRY SEAL PROGRAM: CIP 2012707C
DIMENSION OF INSTALLATIONOR REMOVAL:N/A
PROXIMATE TIME WHEN WORK WILL BEGIN:8/28/2015 TIME OF COMPLETION: 10/16/2015
ESTIMATED CONSTRUCTION COST:S650.000.00 (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 PERMIT CONDII1ONS
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 messge 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.
S
_____
Signature of Applicant or Agent
AMERICAN ASPHALT -JEFF PETTY 14436 SANTA ANA AVE FONTANA, CA 92337 (909)427-8276
Name of Applicant (please print) Business Address Telephone No.
AMERICAN ASPHALT SOUTH INC P 0 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 60423382
Applicant's Insurance Company I Policy Number
Finance Revenue Code
TOTAL: $0.00
PERMIT NO: TC2015-0057
DATE ISSUED: 8/25/2015
EXPIRATION DATE:8/25/2016 •
BY: LEONARD ST. SAUVER
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
Date:
Tract No: Project Name: I
F.
Purpose of Construction (i.e.: Rough Grading, Offsite Street, etc.).Yf &j
.
Description of Construction (i.e.: See Plan Set No. 01234) {2PPik41
Dimension of Installation or Removal:
Approximate Construction Start Date: L8?25/1
Approximate Construction Completion Date 1O/i5I15.'}' Z
Estimated Construction Cost $[65000000 Zcj. &
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: I !EP . Phone Number:P Y6+S
Name of Applicant/Owner
Applicant Address [1436 SNTAAN AV FPNTNA CA3i4+
Applicant Telephone Number 19Q"' 27 IT :
Applicant E-mail A
Name of Contractor: I
Contractor Address jt4436
Contractor Telephone mber:MOA 31"M
Contractor State License Number 784969
Contractor City Business License Number
Contractor E-mail Address FFF@MEP rq
10- A COPY OF THE CURRENT INSURANCE CERTIFICATE MUST BE PROVIDED I
)nlicant or Contractor General Liability Insurance ComDanv:
ADolicant or Contractor General Liability Insurance Policy Number:
Office Use Only:
Inspection Fee:
Permit Fee:
As-Built
Deposit:
Dust Control
Deposit:
Credit
Amount:
TOTAL FEE DUE:
Office Use Only:
Assigned Permit Number:
Approval Date:
Expiration
Date:
issue
Date:
Administrative Authority: