City of Garden Grove
11222 ACACIA PRKWY, GARDEN GROVE, CA 92840
(714) 741-5887 TEL / FAX (714) 741-5578
RIGHT-OF-WAY ENCROACHMENT
PERMIT APPLICATION/AGREEMENT
Project Location: _________________________________
Applicant Name: _________________________________
Company Name: _________________________________
CA State License No.______________________________
Address: _______________________________________
City: _______________________Zip_________________
CELL PHONE: ___________________Office_____________
Email: __________________________________________
INDEMNIFICATION, DEFENSE, AND HOLD HARMLESS: Applicant agrees to defend, indemnify, hold free and harmless the City, its elected and
appointed officials, officers, agents and employees, at the applicant’s sole expense, from and against any and all claims, actions, suits, damage to property
or injuries to or death of any person or persons, including attorney’s fees or other legal proceedings
brought against the City, its elected and appointed officials, officers, agents, and employees arising out
of the performance of the applicant, its employees, contractors, and/or subcontractors, of the work
undertaken pursuant to this Permit. The defense obligation provided for hereunder shall apply without
any advance showing of negligence or wrongdoing by the applicant, its employees, contractors, and/or
subcontractors, but shall be required whenever any claim, action, complaint, or suit asserts as its basis
the negligence, errors, omissions or misconduct of the applicant, its employees, contractors, and/or
whenever any claim, action, complaint, or suit asserts liability against the City, its elected and appointed
officials, officers, agents and employees based upon the work performed by the applicant, its
employees, contractors, and/or subcontractors, under this PERMIT, whether or not the applicant, its
employees, contractors, and/or subcontractors are specifically named or otherwise asserted to be liable.
INSURANCE: The contractor shall procure and maintain, during the entire term of this
Agreement, the insurance coverage as set forth in the City’s “Insurance Requirement for
Contractors”, attached hereto as Exhibit “A” and incorporated herein by this reference.
By signing this document the applicant affirms that they have the authority to act on behalf
of the person/organization for whom this permit is being issued.
Signed_________________________ Date: _______________
Sketch / Plans for Scope of
Work are Required
Inspection is required 48
hours in advance
Any interference with
normal traffic movement
shall have prior approval by
the Traffic Engineering
Division by providing a
Traffic Control Plan for
review.
Number of anticipated
working days_______
THE UNDERSIGNED HEREBY APPLIES FOR PERMISSION TO EXCAVATE, CONSTRUCT, CLOSE TRAFFIC LANES
AND/OR OTHERWISE ENCROACH ON CITY PUBLIC RIGHT-OF-WAY FOR THE FOLLOWING PURPOSE:
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IMPORTANT NOTICE
Section 4216/4217 of the
Government Code requires a Dig Alert
Notification Number be issued before
a “Permit to Excavate” will be valid.
For your Dig Alert ID number call:
DIG ALERT
https://www.digalert.org/home.htm
l
1-800-227-2600
Two Working Days
before you Dig
RE
UIRED INFORMATION
(City Use) Permit No.________