Fillable Form 2118: PUBLICWORKSPERMITAPPLICATION (City of Seal Beach)

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Form 2118: PUBLICWORKSPERMITAPPLICATION (City of Seal Beach)

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File type: PDF

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CITYOFSEALBEACH‐PUBLICWORKSDEPARTMENT
2118
TH
STREET,SEALBEACH,CA90740
PUBLICWORKSPERMITAPPLICATION
PERMITTEEINFORMATION
FOROFFICIALUSEONLY
PERMITTEE: PERMIT#: ISSUEDBY:
CONTACTNAME: ISSUEDATE: EXPIRATIONDATE:
ADDRESS:
PHONE: EMAIL:
OWNERINFORMATION(ifdifferentthanPermittee)
OWNER/CONTACTNAME: PHONE:
ADDRESS:
CONTRACTORINFORMATION
CONTRACTOR: STATELICENSE#/CLASSIFICATION: CITYBUSINESSLICENSE#:
CONTACTNAME: EXPIRATIONDATE: EXPIRATIONDATE:
ADDRESS:
PHONE: EMERGENCYPHONE: EMAIL:
DESCRIPTIONOFWORK
WORKLOCATION:  STREET
ALLEY
PUBLICFACILITY/
BUILDING
DESCRIPTIONOFWORK:(provide3copiesofplans)EXCAVATION
WATER
SEWER
DUMPSTER
COMMUNICATIONS
STREETCLOSURE
OTHER:_________
_
______________
APPLICATIONASSOCIATEDWITHANOTHERPERMIT:
NOYES,(type)________________________________
ASSOCIATEDPERMIT/PROJECT#:
STARTDATE: ENDDATE: #OFWORKINGDAYS: WORKINGHOURS:

MORATORIUM:
YESNO
ENCROACHMENTAGREEMENT:
YESNO
NIGHTWORK:
YESNO
FEES
PERMITFEE:
FOROFFICIALUSEONLY
RECEIPT#:
IFAPPLICABLE,RETURNPERMITDEPOSITTO:
ADDRESS:
v.11/27/19
APPLICATIONDATE:
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Form 2118: PUBLICWORKSPERMITAPPLICATION (City of Seal Beach)

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Completed 16 July 2020

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