Fillable CITY OF SAN DIMAS PUBLIC WORKS DEPARTMENT PERMIT

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CITY OF SAN DIMAS PUBLIC WORKS DEPARTMENT PERMIT

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Country of origin: US
File type: PDF

U.S.A. forms for City of San Dimas

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CITY OF SAN DIMAS PUBLIC WORKS DEPARTMENT
PERMIT APPLICATION
DATE: ___________________________________________________
PROJECT LOCATION: _______________________________________
_________________________________________________________
PROJECT NUMBER (IF APPLICABLE): __________________________
OWNER/APPLICANT:
NAME/ORGANIZATION: ____________________________________
ADDRESS: ________________________________________________
CITY: __________________________ STATE: _______ ZIP: ______
CONTACT NAME: __________________________________________ PHONE:
CONTACT E-MAIL ADDRESS: ___________________________________________________________________________
CONTRACTOR:
NAME/ORGANIZATION: ____________________________________
ADDRESS: ________________________________________________
CITY: _____________________________ STATE: __________________________ ZIP: _________________________
CONTACT NAME: __________________________________________ PHONE:
CONTACT E-MAIL ADDRESS: ___________________________________________________________________________
CITY OF SAN DIMAS BUSINESS LICENSE: ______________ CONTRACTOR LICENSE: ____________ LICENSE CLASS: _____
PROPOSED WORK: _________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
TRAFFIC CONTROL: COMPLY WITH CURRENT CALIFORNIA M.U.T.C.D.
☐
TRAFFIC CONTROL PLAN ATTACHED WORK HOURS:
POWER OUTAGE:
☐
YES
☐
NO TRAFFIC SIGNAL(S) AFFECTED:
☐
YES
☐
NO
INSURANCE:
☐
GENERAL LIABILITY
☐
WORKERS COMPENSATION
☐
EXEMPT (SELF-INSURED)
ITEMS TO BE PERMITTED:
☐A.C. PAVING SF ☐SIDEWALK SF
☐ADJUST MANHOLE QTY ☐TRENCHING LF
☐CURB AND GUTTER LF ☐N.P.D.E.S. B.M.P. REQUIRED (DETERMINED BY CITY STAFF)
☐CURB CORE QTY ☐OTHER: _____
☐DRAINAGE STRUCTURE QTY
☐DRIVE APPROACH SF
☐MAIN LINE LF
☐PULL BOX/SPLICE PIT QTY
☐SEWER LATERAL LF
☐SIDEWALK SF
CALL (909) 394-6240
FOR INSPECTION 24 HOURS
BEFORE START OF WORK
☐CONTAINER/DUMPSTER PERMIT
(MUST BE ORDERED FROM WASTE MANAGEMENT ONLY)
DIMENSIONS OF CONTAINER:
DATE OF CONTAINER/DUMPSTER DROP OFF:
DATE OF CONTAINER/DUMPSTER PICK-UP:
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CITY OF SAN DIMAS PUBLIC WORKS DEPARTMENT PERMIT

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Completed 20 July 2020

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