Fillable Encroachment Permit CITY OF COVINA

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Encroachment Permit CITY OF COVINA

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Covina HP 11.22.10
TWO SIDED DOCUMENT
PAGE 1
CITY OF COVINA
DEPARTMENT OF PUBLIC WORKS
Engineering Services Division
125 East College Street
Covina, CA 91723
Telephone: (626) 384-5490 Fax: (626) 384-5479
APPLICAT I O N FOR ENCROACHMENT PERMIT DATE:_____________
PERMIT TYPE: Utility Cut Sewer Connect Driveway Approach Tree planting/trimming/removal
Construction Excavation Pole Replacement Lot Line Adjustment
Address Change Roll-Off Bin Wide/Oversize Load Street/Lane Closure
Plan Review Curb and Gutter Equipment/Materials Other, Unlisted Work: _______________
OWNER/APPLICANT: PHONE:
( ) -
PRINT NAME SIGNATURE
ADDRESS:
STREET CITY ZIP CODE
EMAIL ADDRESS:
I hereby make application for permit to encroach into the public right-of-way at the described location(s). It is agreed by the applicant that the City
of Covina and any of its officers or employees thereof shall be held harmless by the applicant from any liability or responsibility for any accident,
loss or damage to persons, property, highway or public right-of-way, happening or occurring as the approximate results of any of the work
undertaken under the terms of this application and that all of said liability is hereby assumed by the applicant including all attorney fees, costs
and expenses paid in defense or prosecution of an indemnity claim or appeal of such claims.
Permit void if work is not started and inspection not requested within 180 days of date of permit issuance. I am/We are aware of, and will comply
with, Section 3800 of the Labor Code, regarding Liability insurance for Workman’s Compensation or undertake self-insurance before commencing
any of the work. IT IS FURTHER AGREED THAT THE OWNER/APPLICANT IS THE FINANCIALLY RESPONSIBLE PARTY FOR
INITIAL DEPOSITS, ADDITIONAL COLLECTIONS, CHARGES AND REFUNDS.
CONTRACTOR: PHONE:
( ) -
PRINT NAME SIGNATURE
ADDRESS:
STREET CITY ZIP CODE
EMAIL ADDRESS:
BUSINESS LICENSE NO.: ______________________________________ WORK ORDER NO.:
SITE ADDRESS:
STREET CITY ZIP CODE
SCOPE OF WORK:
START/END DATE: USA “DIGALERT NO. :
WIDE/OVERSIZE LOAD ROUTE:
DATE/TIME OF TRANSPORATION: LOAD OR EQUIPMENT:
HEIGHT: LENGTH: WIDTH:
*PAYER: *PAYER SIGNATURE:
** THE OWNER/APPLICANT IS THE FINANCIALLY RESPONSIBLE PARTY FOR ADDITIONAL COLLECTIONS, CHARGES AND REFUNDS.
PERMIT APPROVAL AND ACCEPTANCE OF WORK
CALL Walter G. Pruszynski -Public Works Inspector at (909) 594-9702
at least 1 week PRIOR to all required inspections.
In compliance with the above application and subject to all the terms, conditions and restrictions written or printed as provisions on any part of this
form and attached hereto, permission is granted to encroach or perform work within public rights-of-way. City of Covina reserves the right to amend
permit as conditions apply.
Work was hereby inspected and accepted by the City.
Inspector’s Signature: Date:
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Covina HP 11.22.10
TWO SIDED DOCUMENT
PAGE 2
CITY OF COVINA
DEPARTMENT OF PUBLIC WORKS
Engineering Services Division
REQUIREMENTS FOR OBTAINING A PERMIT
1. Complete and sign the permit application. Payment collection will be required prior to permit issuance. Only complete
permit application packages will be accepted for review and processing.
2. Submit 2 sets of plans showing the location of work proposed; relative to the right-of-way boundary or the centerline
of the road. Pipelines and utilities should be shown parallel to, and at a constant distance from the right-of-way or
roadway centerline.
3. Provide proof of General Liability and Workers Compensation insurance. All insurance documents, including the
required endorsement form, must name City of Covina as “Additionally Insured” per current insurance requirements.
4. Submit a copy of contractor’s license.
5. Provide cash deposit/security, the amount based on an estimate incurred if the permittee does not fulfill the permit
work. The security deposit will be returned when the permitted work has been completed and approved by the Public
Works Construction Inspector.
6. For Street/Lane Closure: Submit 2 sets of traffic control plans showing the location of work proposed; relative to the
right-of-way boundary or roadway centerline. One (1) lane of traffic in each direction is to be kept open and clear at
all times.
PROVISIONS
· All work in public right-of-way shall be per Standard Specifications for Public Works Construction (S.S.P.W.C.), City
standards, policies, codes and these Provisions to the satisfaction of the Public Works Director or his/her representatives.
· All inspection costs incurred incidental to this work shall be borne by the Permittee unless otherwise specified on the face of
the permit.
· Utilities damaged or broken by the Permittee shall be repaired or replaced to the satisfaction of their owners at
Permittee’s expense. Any trees, shrubbery, or landscaping damaged shall be replaced as directed by the Public Works Director.
· Any concrete to be removed shall be saw cut and replaced as directed to match existing in: color, finish and scoring. Pavement
to be removed shall be restored within 30 days of installation of facilities covered under permit.
· All traffic interference, control, detours, and lane closures shall be made in accordance with latest approved “Manual of Uniform
Traffic Control Devices” (MUTCD) and are subject to the Public Works Director’s prior review and approval.
· All trenches and/or open holes shall be filled, covered, or plated and adequately barricaded at the end of each day and
whenever work is not in progress.
· Construction work in the public right-of-way shall be done between the hours of 8:30 a.m. and 4:00 p.m.
· Permittee shall obtain a State Division of Industrial Safety Excavation permit and file copy of same with Public Works Director
prior to start of underground permitted work.
· Compaction tests required at locations and depths as determined by Public Works Director at cost of Permittee.
Compaction shall be per current S.S.P.W.C. (Greenbook) requirements.
· Jack/bore, when allowed by Public Works Director, are as shown on plan.
· Pavement replacement shall be in conformance with current A.P.W.A and City Standards concrete pavement Class 560 A 3250.
· Permittee shall remove all Underground Service Alert markings by method approved by the Public Works Director.
· Special paving conditions will be required on newly paved or resurfaced roadways.
· Roll-off debris containers must have the following clearly displayed and visible on its exterior surface:
Permitee’s name and telephone number (including area code) in print at least two inches in height;
3-inch diameter reflectors, placed on the four corners of each side of the roll-off debris container facing traffic. The
lower deflectors shall be between 3 and 4 feet above the ground and vertically aligned with the upper reflectors.
· The area surrounding a permitted roll-off debris container shall be maintained in a clean manner, free from any trash
or deleterious material.
· Permitted roll-off debris container shall be secured in such a manner so as to prevent any movement, other than during
placement and removal.
· Additional conditions: Attached (Check if applicable)
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Encroachment Permit CITY OF COVINA

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Completed 3 August 2020

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