TC2015-0072c .it 4 .4z uift1a, See below for Finance Revenue Codes
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ENCROACHMENT PERMIT Is
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: 10/12/2015
LOCATION *OF CONSTRUCTION(Street address or Description): MONROE STREET AND AVE 54
PURPOSE OF CONSTRUCTION: MONORE STREET IMPROVEMENTS: AC PAVING AND HCAP RAMPS
DESCRIPTION OF CONSTRUCTION: TRAFFIC CONTROL FOR CIP 2014-16: MONROE ST. IMPROVEMENTS
DIMENSION OF INSTALLATION OR REMOVAL:
TE TIME WHEN WORK WILL BEGIN: 10/13/2015 TIME OF COMPLETION: 11/1/2015
ESTIMATED CONSTRUCTION COST: S216.000.00 (Including removal of all obstruction, materials, and debris, backfilling, compaction
and placing permanent resurfacing and/or replacing improvements)
SEE PROJECT CONTRACT AND SPECIFICATIONS FOR CIP 2012-07B 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.
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Signature of Applicant or Agent
MATICH CORPORATION
Name of Applicant (please print)
MATICH CORPORATION
Name of Contractor and Job Foreman
149783
Contractor's License No.
P 0 BOX 10 HIGHLAND, CA 92346 (909)382-7400
Business Address Telephone No.
P 0 BOX 10 HIGHLAND, CA 92346 (909)382-7400
Business Address Telephone No.
LIC-0000595
City Business License No.
OLD REPUBLIC GENERAL INSURANCE CORP. A1CG43921513
Applicant's Insurance Company Policy Number
Finance Revenue Code
TOTAL: $0.00
PERMIT NO: TC2015-0072
DATE ISSUED: _____
EXPIRATION DATE
BY:L
WORK INSPECTED BY:
PERMIT COMPLETION DATES:
51f 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: ,i4v1&' ' "
Vicinity: Sr 40b s/
Purpose of Construction (i.e.: Rough Grading, Mite Street, etc.)____________
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Description of Construction (i.e.: See Plan Set No. 01234) Ac- 94WN6
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Dimension of Installation or Removal:
I Approximate Construction Start Date:
Approximate Construction Completion Date:
Estimated Construction Cost: $ 2 /. cc7'
Estimated Construction Cost shall include the removal of all ol1ructions, materials, and debris, back-filling, compaction and
placing permanent resurfacing and or replacing improvements
Contact Name:. Re)&fAjr P114 7C?/ Phone Number: 9e gz- 79CO
Name of Applicant/Owner: 4447_/-A' cn2PO'- Th9/J/
Applicant Address:
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Applicant Telephone Number:
Applicant E-mail Address:
Name of Contractor: ,4A41!C-W cP1
ContractorAddressø. 340 Ic' I.4f,14L,PtMO C 12494.
Contractor Telephone Number: 'k017 2 -2.-
Contractor State License Number: ij 'j 9 T3
Contractor City Business License Number: O51 .S
Contractor E-mail Address: • ('f . k a t c rp
10- A COPY OF THE CURRENT INSURANCE CERTIFICATE MUST BE PROVIDED 4
Applicant or Contractor General Liability Insurance Company:
0 I PAwhts C &twa'- . 9'
Applicant or Contractor General Liability Insurance Policy Number: e_)/, -2/1 (,
31?, 1 ,571
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Office Use Only:
Inspection Fee:
Permit Fee:
As-Built
Deposit:
Dust Control
Deposit:
Credit
Amount:
TOTALFEEDIJE: ..Tj I
urlveI(necKIlsts - Forms & AppllcatlonslADDiication fo
Office Use Only:
Assigned Permit Number72 o I .s"-j 00'? 2—
Approval Date:
Expiration
Dale:
Issue
Date:
Administrative Authority: