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: