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OWNER/ PROJECT INFORMATION (City of Long Beach California)

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Revision Date: March 2020
Page 1
I the undersigned declare, under penalty of perjury under the laws of the State of California, that I am the owner or authorized representative;
that the information on all plans, drawings, and sketches attached hereto and all the statements and answers contained herein are, in all
respects, are true and correct.
NAME (PRINTED) SIGNATURE DATE
__________________________________________________________________________
Send the complete application and all required submittals via e-mail to PW-PrivateDevelopment@longbeach.gov
OWNER/ PROJECT INFORMATION
This section must be completed for all applications.
PERMIT (OFFICE USE)
NUMBER :
DATE:
PROJECT ADDRESS
PROJECT NAME (IF ANY)
OWNER CONTACT NAME
OWNER EMAIL ADDRESS
BUSINESS ADDRESS
CITY
ZIP CODE
FRANCHISE AND/OR MASTER AGREEMENT NUMBER (IF APPLICABLE)
DESCRIPTION OF PROJECT/ REASON FOR APPLICATION
OWNER'S AGENT INFORMATION
This section must be completed if the applicant is
NOT the owner.
APPLICANT NAME
APPLICANT EMAIL ADDRESS
RELATIONSHIP TO THE OWNER (Must include an authorization letter to act on the owner’s behalf)
(LBMC 14.08.030.B.7)
☐ DESIGNER
☐ OWNER'S AGENT ☐ LESSEE/TENANT ☐ CONTRACTOR ☐
OTHER:
APPLICANT'S BUSINESS NAME/DBA
PHONE NUMBER
ADDRESS
CITY
ZIP CODE
BUSINESS NAME
DEPARTMENT OF PUBLIC WORKS
411 W Ocean Blvd.
Long Beach CA 90802
Revision Date: March 2020 Page 2
CONTRACTOR INFORMATION
This section is required for all work applications except
for mapping/ survey, PWOP renewals or parklet renewals.
STATE LICENSE NUMBER CLASS EXPIRATION DATE
CITY BUSINESS LICENSE NUMBER*
EXPIRATION DATE
LIABILITY INSURANCE CARRIER*
POLICY NUMBER
EXPIRATION DATE
BUSINESS NAME
PHONE NUMBER
EMAIL ADDRESS
ADDRESS
CITY
STATE
ZIP CODE
ADDITIONAL CONTACT/SITE CONTACT NAME
PHONE NUMBER
ITEMS THAT MUST ACCOMPANY THIS APPLICATION
☐ Construction schedule
☐ List of subcontractors and applicable contractors license
☐ Contractor's Certificate of Insurance
☐ Completed City Insurance Endorsement Form or Additional Insured Endorsement (CG 20 12 or CG 20 26)
☐ Statement of approximate value for work within the right of way/ park
*NOTE: TEMPORARY OCCUPANCY PERMITS CAN ONLY BE ISSUED OVER THE COUNTER IF THE
CONTRACTORS BUSINESS LICENSE AND INSURANCE IS ALREADY IN THE CITY DATABASE AND
CURRENT. IF NOT, A MINIMUM 10 DAY REVIEW PERIOD IS REQUIRED.
DEPARTMENT OF PUBLIC WORKS
411 W Ocean Blvd.
Long Beach CA 90802
Revision Date: March 2020 Page 3
MAPPING/ SURVEY
Complete this section ONLY IF applying for
mapping/ survey activities noted below.
DESCRIPTION
VACATION PARCEL MAP TRACT MAP LOT LINE ADJUSTMENT
EASEMENT GRANT OF EASEMENT DEDICATION QUITCLAIM
RIGHT OF WAY TO BE VACATED: EAST OF AND NORTH OF
AREA IN SQUARE FEET TO BE VACATED (VACATION ONLY)
# OF LOTS (MAPS ONLY)
COMMENTS/REMARKS
ITEMS THAT MUST ACCOMPANY THIS APPLICATION
ITEMS THAT MUST ACCOMPANY ALL APPLICATIONS
Title documents (title report or grant deed) less than 90 days old.
Survey tie sheets (not required for QUITCLAIM)
Articles of incorporation (if LLC)
CEQA categorical exemption or environmental review (can be provided after application submission)
Date Received:
Notice of Final Action (If applicable. Can be provided after application submission) [Application #____________ ]
ADDITIONAL ITEMS THAT MUST ACCOMPANY A VACATION APPLICATION
Legal description and sketch prepared by a licensed surveyor
Engineer’s estimates for the performance, labor, and materials bonds
Performance, labor, and materials bonds (provided after estimate has been reviewed)
ADDITIONAL ITEMS THAT MUST ACCOMPANY A GRANT
OF EASEMENT, EASEMENT, OR DEDICATION
APPLICATION
Legal description and sketch prepared by a licensed surveyor
ADDITIONAL ITEMS THAT MUST ACCOMPANY A QUIT CLAIM APPLICATION
Legal description and sketch prepared by a licensed surveyor
Confirmation letter from easement grantor that the easement is no longer required
Copy of the easement to be quit claimed
ADDITIONAL ITEMS THAT MUST ACCOMPANY A MAP APPLICATION
FEE (Office Use)
$
6.2% SURCHARGE
$
TOTAL FEE
$
Parcel/ Tract Map on City Template
Engineer’s estimates for the performance, labor, and materials bonds
P
erformance, labor, and materials bonds (provided after estimate has been reviewed)
Confirmation that tax requirements are satisfied
Utility clearance letters for any public entity or utility
DEPARTMENT OF PUBLIC WORKS
411 W Ocean Blvd.
Long Beach CA 90802
Revision Date: March 2020
Page 4
Complete Only the following sections (A-F) that apply to your project. Typically, only a single
section (A-F) needs to be completed.
A – TEMPORARY
OCCUPANCY PERMIT
(Less than 90 days)
Complete this section ONLY IF your project includes minor
occupancy with no intrusion AND City Standard Traffic Control
Plan is applicable. Examples include; utilizing a parking stall
for material deliveries, laydown, storage of equipment, trash
bin, parking of construction vehicles, etc. Minor improvement
work can be completed under this permit as outlined below.
PERMIT TYPE (CHECK AS APPROPRIATE)
IN COMPLIANCE WITH THE FOLLOWING STANDARD
Replacement of existing residential driveway
Closure of residential driveway
Installation of ADA ramp
Replacement of curb and gutter less than 50 linear feet
Replacement or Installation of sidewalk less than 50 linear feet
Occupancy of 1-2 parking stalls (trash bin, pod, laydown)
Window Washing
Other activity using non-Arterial ROW for less than 90 days
City Standard Plan
City Standard Plan
City Standard Plan
City Standard Plan
Standard Plan for Public Construction
City Standard Plan
ITEMS THAT MUST ACCOMPANY THIS APPLICATION
ITEMS THAT MUST ACCOMPANY ALL APPLICATIONS
☐ Site plan/ staging drawings identifying total area of ROW being used/ occupied
☐ Photos of existing conditions of the area
☐ Details of the installation/ work being completed
☐ Traffic control drawings per City of Long Beach Standard Traffic Plans
FEE (Office Use)
$
6.2% SURCHARGE
$
TOTAL FEE
$
B - PUBLIC ART/ OBJECTS
Complete this section if your project includes artwork or
installation of other objects (mailboxes, news racks,
benches, etc.) within the ROW
ITEMS THAT MUST ACCOMPANY THIS APPLICATION
☐ Site plan drawings
☐ Photos of existing conditions of the area
☐ Details of the installation
☐ Renderings of the artwork (if applicable)
☐ Letter of approval from homeowner’s association (HOA) OR community association (If No HOA) (if artwork)
☐ Completed installation and maintenance agreement (IMA)
☐ Articles of incorporation or other means to verify authority to sign IMA.
NOTE: This must match with the information filed with the Secretary of State
FEE (Office Use)
$
6.2% SURCHARGE
$
TOTAL FEE
$
DEPARTMENT OF PUBLIC WORKS
411 W Ocean Blvd.
Long Beach CA 90802
Revision Date: March 2020
Page 5
C – RIGHT-OF-WAY OCCUPANCY/
EXCAVATION
Complete this section if your project includes any of the following
activities
:
- Occupancy of the ROW for more than 90 days
- Occupancy on an Arterial Street (regardless of duration of work)
- Excavation on private property 3’ or more below grade
- Excavation within the ROW 10” or more below grade
- New or addition to Multifamily or Nonresidential building
- Not required for E-PWOP or F-WTF
ITEMS THAT MUST ACCOMPANY ALL APPLICATIONS
☐ Notice of Final Action and Conditions of Approval (if applicable) [Application # __________________________ ]
☐ Drawings clearly identifying total area of ROW being occupied and any meters being impacted
☐ Traffic control drawings (for non-standard plans use 1:40 scale)
☐ Scaffolding plan and engineering calculations (if installed within ROW)
☐ Graphic fence wrap for temporary fencing (if project is longer than 6 months)
ADDITIONAL ITEMS THAT MUST ACCOMPANY EXCAVATION OR GRADING WORK
☐ Excavation drawings (if excavation is greater than 3’ deep)
☐ Haul route plan (if hauling spoils)
☐ Hydrology report
☐ Dewatering report (if applicable)
☐ Geotechnical report (if applicable)
☐ Shoring plans (if excavation is greater than 5’ deep)
☐ Tie back agreement (if applicable, LBMC 14.08.170)
☐ On-site grading & drainage plan (Applicable to New or Additions on Multifamily Dwellings and Nonresidential
Buildings)
ADDITIONAL ITEMS THAT MUST ACCOMPANY TRENCHING OR UTILITY WORK
☐ Civil drawings clearly identifying total area (in square feet) of ROW being excavated AND repaired
☐ Approved design/ authorization from applicable utilities (SCE, LBWD, LB Fire, LA County…)
ADDITIONAL ITEMS THAT MUST ACCOMPANY MONITORING WELL WORK
☐ Health Department well permit
☐ Depth of well details
☐ Security (Cash, bond, CD) in the amount of $5,000 per monitoring well
☐ Completed Installation and Maintenance Agreement (IMA)
☐ California Regional Water Quality Control Board Letter of Approval
FEE (Office Use)
$
6.2% SURCHARGE
$
TOTAL FEE
$
Applicants often request an Occupancy AND/OR Excavation Permit ahead of the Right of Way Improvement Permit due to
project phasing or other reasons. For this reason, we have separated out the requirements, but an applicant can submit
both at the same time for a single review and permitting process.
DEPARTMENT OF PUBLIC WORKS
411 W Ocean Blvd.
Long Beach CA 90802
Revision Date: March 2020
Page 6
D - RIGHT OF WAY/ PARK
IMPROVEMENT(S)
Complete this section ONLY IF your project includes
right of way improvements. This includes but is not
limited to: paving of streets or alleys, installation of new
driveway, curb, sidewalk, gutter, and/ or storm drains,
upgrades to traffic signals, striping, parkway
improvements etc. This section is not required for
repairs due to utility tie in or monitoring wells.
Applicants often request an Occupancy AND/OR Excavation Permit ahead of the Right of Way Improvement Permit due
to project phasing or other reasons. For this reason, we have separated out the requirements, but an applicant can
submit both at the same time for a single review and permitting process.
ITEMS THAT MUST ACCOMPANY THIS APPLICATION
To expedite review, even if the following items were submitted previously for an excavation permit they MUST be
resubmitted. This ensures that any changes are properly captured and that there is no delay in project review and
permit issuance.
HAS AN OCCUPANCY/ EXCAVATION PERMIT ALREADY BEEN ISSUED?
☐ Yes, and there are no changes to any of the previously approved items
☐ Previous Permit #: _____________________________________
☐ Yes, but there are some changes to the previously approved items
☐ Previous Permit #:
_____________________________________
☐ Submit all applicable documents with revisions clouded
☐ No, a consolidated review and permitting process is requested
☐ Complete the occupancy/ excavation section of this application and include all required submittals
ITEMS THAT MUST ACCOMPANY ALL APPLICATIONS
☐ Civil Improvement drawings
☐ Civil Drainage drawings
☐ Precise grading drawings
☐ Striping drawings
☐ Traffic signal drawings
☐ Landscape and irrigation drawings
☐ Arborist report (
if trees are being removed or trimmed)
☐ Engineers estimate for the ROW improvements
☐ Cut sheet or Spec sheet for equipment (if applicable)
☐ Traffic impact analysis (if more than 100 vehicle trips per day)
ADDITIONAL ITEMS THAT MUST ACCOMPANY A PROJECT WITH MATERIALS THAT DEVIATE FROM THE STANDARDS
(Examples: decorative pavers, decorative crosswalk art, or other items noted within the conditions of approval)
☐ Completed installation and maintenance agreement (IMA)
☐ Articles of incorporation or other means to verify authority to sign IMA.
NOTE: This must match with the information filed with the Secretary of State
FEE (Office Use)
$
6.2% SURCHARGE
$
TOTAL FEE
$
DEPARTMENT OF PUBLIC WORKS
411 W Ocean Blvd.
Long Beach CA 90802
Revision Date: March 2020
Page 7
E - PUBLIC WALKWAYS OCCUPANCY
Complete this section ONLY IF your project includes
sidewalk dining or a parklet
Permit Type:
New
Renewal (No Changes)
Renewal (Minor Modifications)
Change of Ownership
ITEMS THAT MUST ACCOMPANY THIS APPLICATION
ITEMS THAT MUST ACCOMPANY A NEW APPLICATION
Drawings and specifications as applicable for the improvement
Site plan drawings including all existing items and utilities within right of way clearly identifying area (in square
feet) the total area being occupied
Seating and equipment drawings
Detail drawings/ cut sheet of the barrier/ railing and any equipment stamped by a CA registered engineer
Photos of existing conditions of the area
Renderings of the installation
Landscape and irrigation drawings (if applicable)
Arborist report (if trees are being removed or trimmed)
Completed installation and maintenance agreement (IMA)
Articles of incorporation or other means to verify authority to sign IMA.
NOTE: This must match with the information filed with the Secretary of State
Comprehensive certificate of liability insurance. Liquor liability must be included if serving beer, wine or liquor
Completed City Insurance Endorsement Form
Liquor license. NOTE: extension of premise can be provided after the PWOP is installed (if applicable)
Engineers estimate for the cost of removal of the PWOP
Security Deposit in the amount of the engineers estimate for the cost of removal of the PWOP
California Coastal permit (if within the coastal zone)
ADDITIONAL ITEMS THAT MUST ACCOMPANY A NEW PARKLET APPLICATION
Detail drawings of the platform and barricade stamped by a CA registered engineer
Letter of approval from building owner, homeowners association (HOA) OR community association
Location of relocated parking meters (if applicable)
Traffic control drawings (for non-standard plans use 1:40 scale or 1:60 scale)
ITEMS THAT MUST ACCOMPANY A RENEWAL APPLICATION
Previous permit or agreement
Photos of existing conditions of the area
Detail drawings of any modifications/ changes being requested (if minor modifications)
Comprehensive certificate of liability insurance. Liquor liability must be in
cluded if serving beer, wine or liquor
Completed City Insurance Endorsement Form
ITEMS THAT MUST ACCOMPANY A CHANGE OF OWNERSHIP
All items required for a renewal application
Completed installation and maintenance agreement (IMA)
Articles of incorporation or other means to verify authority to sign IMA.
NOTE: This must match with the information filed with the Secretary of State
A letter from the previous owner relinquishing the security deposit to the new owner
OR
Engineers estimate for the cost of removal of the PWOP
Security Deposit in the amount of the engineers estimate for the cost of removal of the PWOP
FEE (Office Use)
$
6.2% SURCHARGE
$
TOTAL FEE
$
DEPARTMENT OF PUBLIC WORKS
411 W Ocean Blvd.
Long Beach CA 90802
Tier B (Protected)
Revision Date: March 2020
Page 8
F – WIRELESS
TELECOMMUNICATION FACILITY
Complete this section ONLY IF your project includes
installation of a wireless telecommunications facility.
(Submit Power and Fiber under Section C)
Type of Permit applying for (select only one):
Tier A (Unprotected) Modification Renewal
#
Pole #
Property Address Adjacent to Installation
GIS Coordinates
1
2
3
4
5
6
7
8
9
10
ITEMS THAT MUST ACCOMPANY THIS APPLICATION
Items required at time of application submission:
Site plan drawings (LBMC 15.34.030.D.2-3)
Electrical drawings (LBMC 15.34.030.D.11)
Structural drawings/calculations (LBMC 15.34.030.D.10)
Photos of existing conditions of the surrounding area(s) (LBMC 15.34.030.D.5)
Photo simulation of proposed project (LBMC 15.34.030.D.12)
Traffic control drawings (for non-standard plans use 1:40 or 1:60 scale) (LBMC 15.34.030.D.9)
Landscape drawings (if applicable) (LBMC 15.34.030.B.1.b.x.3)
Propagation/Coverage Maps (if denial would cause a “significant coverage gap”) (LBMC 15.34.030.D.6)
CEQA categorical exemption or environmental review (if not covered under blanket exemption)
Approval letter from the Cultural Heritage Commission (if placed on a designated Historic Landmark)
GIS map of the proposed location(s) showing underground conduit runs in shapefile or KMZ file format (LBMC
15.34.030.D.4)
Completed antenna, equipment and site location preference form (see pages 9 & 10) (LBMC 15.34.030.B.1.b.vi)
Items that can be provided after application submission:
Radio frequency engineering report (LBMC 15.34.030.D.7)
Noise analysis (manufacturer's specifications acceptable) (LBMC 15.34.030.D.14)
Construction phasing plan (LBMC 15.34.030.D.15)
Maintenance plan (LBMC 15.34.030.D.9)
Joint pole commission approval letter for wooden poles only (if applicable) (LBMC 15.34.030.B.1.b.ii)
ADDITIONAL ITEMS THAT MUST ACCOMPANY A TIER B (PROTECTED LOCATION) APPLICATION
Letter explaining the installation(s) will not significantly detract from any defining characteristics of the area or the view
corridor (LBMC 1
5.34.020.Z)
Item that can be provided after application submission:
Confirmation of public notification, including notice by mail and notice by posting (required prior to permit issuance)
(LBMC 15.34.030.K.1-3)
FEE (Office Use)
$
6.2% SURCHARGE
$
TOTAL FEE
$
Site Number
DEPARTMENT OF PUBLIC WORKS
411 W Ocean Blvd.
Long Beach CA 90802
Revision Date: March 2020
Page 9
Per LBMC 15.34.030.B.1.b.vi Aesthetic Impacts, all wireless telecommunication facilities shall be designed and located
to elim
inate or substantially reduce their visual and aesthetic impacts upon the surrounding public rights-of-way and
public vantage points. To accomplish this goal, all wireless telecommunication equipment shall be developed with the
intent of locating and designing such facilities in the order of preference (from top to bottom) as outlined below. In
instances where a facility is proposed at a location, or in a manner, that is not the highest preference (top of list), the
applicant shall make a factual showing that ALL higher preferences are infeasible. Attach additional sheets as
necessary.
If applying for more than one facility on a single permit, the antenna, equipment AND site preferences shall be the same
for each location. If they are not the same, a separate application is required.
ALL higher preferences not selected MUST contain a factual statement about infeasibly.
Impact Element
Reason for Infeasibility
Antenna Preferences (check the box of the preference being used)
i.
☐
Existing street light pole (No
infeasibility statement required if
this option is selected)
ii.
☐
Replacement street light pole
iii.
☐
Existing structure other than a
street light pole or utility pole
iv.
☐
New structure other than a
street light pole or utility pole (e.g.,
wireless kiosk)
v.
☐
Existing non-wood utility pole
vi.
☐
New non-wood utility pole
vii.
☐
Existing wood utility pole
DEPARTMENT OF PUBLIC WORKS
411 W Ocean Blvd.
Long Beach CA 90802
Revision Date: March 2020
Page 10
Impact Element
Reason for Infeasibility
Equipment preferences (check the box of the preference being used)
i.
☐
Bundled in an all-in-one equipment
cabinet with the antenna (No infeasibility
statement required if this option is
selected)
ii.
☐
Below-grade equipment
vault, or on a street light or utility pole that
does not place new cabinets or other
above ground furniture, and the power
supply equipment is undergrounded
iii.
☐
Attached to existing power source in
an existing utility box;
iv.
☐
Enclosed at the base of the pole on
which the antenna is proposed for
installation
v.
☐
In an existing ground-mounted (grade-
level) equipment cabinet, with no
expansion or additional cabinets to be
added
vi. ☐ Within a new equipment enclosure 26
mounted at grade.
Impact Element
Reason for Infeasibility
Site Location Preferences (check the box of the preference being used)
i. ☐ Not in a center median, not requiring
removal of parkway trees or landscaping,
and not requiring modifications or
relocation of existing infrastructure
ii.
☐
Requires minor alteration to the
existing public improvements and/or
infrastructure (i.e. reduction of landscape
area)
iii.
☐
Requires significant alteration to the
existing public improvements and/or
infrastructure (i.e. removal of a street tree
or relocation of infrastructure)
DEPARTMENT OF PUBLIC WORKS
411 W Ocean Blvd.
Long Beach CA 90802
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OWNER PROJECT INFORMATION (City of Long Beach California)

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Completed 3 August 2020

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