PERMIT NUMBER:
EXPIRATION DATE:
ZIP COD
E
ZIP COD
E
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SIGNATURE OF APPLICANT DATE
SIGNATURE OF CONTRACTOR DATE
PERMIT FEE AMOUNT
INSPECTION FEE
ISSUANCE
DEPOSIT
MISC.
DEPOSIT 129
SPECIAL
INSPECTION 140
TOTAL
ISSUED BY:
CITY STAFF SIGNATURE DATE
PAYMENT VALIDATION
I HEREBY AFFIRM THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BEC
OME SUBJECT TO THE WORKER'S COMPENSATION LAWS OF CALIFORNIA.
NOTICE TO CONTRACTOR: IF, AFTER THIS CERTIFICATE OF EXEMPTION, YOU SHOULD BECOME SUBJECT TO THE WORKERS COMPENSATION PROVISIONS OF THE LABOR CODE, YOU MUST FORTHWITH COMPLY WITH SUCH PROVISIONS OR THIS
PERMIT SHALL BE DEEMED REVOKED. I CERTIFY THAT APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL CITY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HEREBY
AUTHORIZE REPRESENTATIVES OF THIS CITY TO ENTER UPON THE ABOVE MENTIONED PROPERTY FOR INSPECTION PURPOSES.
SECTION 4216/4217 OF THE GOVERNMENT CODE REQUIRES A DIG ALERT
IDENTIFICATION NUMBER BE ISSUED BEFORE A "
PERMIT TO EXCAVATE" WILL BE
VALID FOR YOUR DIG I.D. NUMBER CALL UNDERGROUND SERVICE ALERT AT 811
TWO WORKING DAYS BEFORE YOU DIG.
PUBLIC RIGHT-OF-WAY ENCROACHMENT PERMIT
APPLICANT ADDRESS
CONTRACTOR ADDRESS
APPLICANT EMAIL ADDRESS
NUMBER OF DAYS TO COMPLETE THE WORK
CONTRACTOR CONTACT NAME
EST. START DATE
CONTRACTOR CON
TACT PHONE NO.
PHONE NUMBER
PHONE NUMBER.
APPLICANT NAME
CONTRACTOR BUSINESS NAME
CONTRACTOR LICENSE NUMBER
CITY LICENSE NUMBER
CERTIFICATE OF EXEMPTION F
ROM WORKER'S COMPENSATION INSURANCE
SIGNATURE OF CONTRACTOR
CITY S
TAFF USE
ONLY
LOCATION OF WORK
DESCRIPTION OF WORK
CONDITIONS OF PE
RMIT
PERMITTEE SHALL INDEMINFY, DEFEND, AND HOLD THE CITY, ITS OFFICIALS, OFFICERS, REPRESENTATIVES, EMPLOYEES, AUTHORIZED AGENTS AND VOLUNTEERS, FREE AND HARMLESS FROM ANY AND ALL CLAIMS, DEMANDS, CAUSES
OF ACTION, COSTS, EXPENSES, LIABILITIES, LOSSES DAMAGES OR INJURIES, IN LAW OR EQUITY, TO PROPERTY OR PERSONS, INCLUDING WRONGFUL DEATH, IN ANY MANNER ARISING OUT OF OR INCIDENT TO ANY ALLEGED ACTS,
OMISSIONS OR WILLFUL MISCONDUCT ARISING OUT OF OR IN CONNECTION WITH ANY WORK ON THE PROPERTY UNDERTAKEN PURSUANT TO THIS PERMIT, INCLUDING WITHOUT LIMITATION THEY PAYMENT OF ALL CONSEQUENTIAL DAMAGES, ATTORNEY'S
FEES AND OTHER RELATED COSTS AND EXPENSES.
THE CITY SHALL RESERVE THE RIGHT TO ADD OR DELETE ANY CONDITION OR REQUIREMENT OF THIS PERMIT SUBSEQUENT TO ITS ISSUANCE WHICH IT MAY DEEM NECESSARY TO MEET CONSTRUCTION STANDARDS, PREVENT
INTERFERENCE WITH TRAFFIC, OR ASSURE SAFETY OR PERSONS USING THE RIGHT-OF-WAY.
THE CITY ENGINEER MAY CANCEL THE PERMIT IF THE WORK AUTHORIZED THEREIN IS NOT COMMENCED WITHIN THIRTY (30) DAYS OF THE ISSUANCE OF THE PERMIT AND THEREAFTER, IF IN THE OPINION OF THE CITY ENINEER,
IS NOT DILIGENTLY PROSECUTED TO COMPLETION.
TRAFFIC CONTROL DEVICES SHALL BE IN PLACE PRIOR TO START OF WORK. THE "WORK AREA TRAFFIC CONTROL HANDBOOK"( WATCH MANUAL) OR THE "STATE OF CALIFORNIA, DEPARTMENT OF TRANSPORTATION MANUAL OF
UNIFORM TRAFFIC CONTROL DEVICES" PART 6, "TEMPORARY TRAFFIC CONTROL" CURRENT EDITION SHALL BE USED AS A GUIDE FOR SUCH TRAFFIC CONTROL, SUBJECT TO REQUIREMENTS OF THE ISSUING OFFICE.
IF ANY PART OF THIS INSTALLATION INTERFERES WITH THE FUTURE USE, CONSTRUCTION, OR REPAIR OR CITY FACILITIES OR PUBLIC UTILITY, THE INSTALLATION SHALL BE REMOVED OR RELOCATED, AS DESIGNATED BY THE CITY OF YORBA LINDA, AT THE
EXPENSE OF THE PERMITTEE OR THE PERMITTEE'S SUCCESSOR IN INTEREST.
ANY DAMAGE TO CITY PROPERTY OCCURRING DURING THE PERFORMANCE OF THE UNDER THIS PERMIT SHALL BE REPAIRED TO THE SATISFACTION OF THE CITY ENGINEER. ANY CONSTRUCTION OR REPAIR MADE OR RESULTING FROM
THIS PERMIT, WHICH HAS FAILED IN THE OPINION THE CITY ENGINEER, SHALL REPAIRED OR REPLACED AT THE EXPENSE OF THE PERMITTEE.
ANY REFUND OF DEPOSITS SHALL BE RETURNED TO THE PAYER OF THE DEPOSIT. ANY AND ALL REFUNDS SHALL BE ISSUED ONLY AFTER ALL REQUIRED INSPECTIONS HAVE BEEN PERFORMED AND THE PROJECT FOR WHICH THIS PERMIT
IS ISSUED HAS BEEN FINALLY APPROVED.
IF DEPOSIT IS INSUFFICIENT TO PAY ALL FEES AND COSTS NECESSARY, THE PERMITTEE SHALL, UPON DEMAND, PAY TO THE CITY OF YORBA LINDA AN AMOUNT EQUAL TO THE DEFICIENCY. IF PERMITTEE FAILS TO PAY ANY DEFICIENCY AS PROVIDED, THE CITY MAY RECOVER THE
SAME BY AN ACTION IN ANY COURT OF COMPETENT JURISDICTION. PERMITTEE SHALL BEAR ANY AND ALL COSTS, INCLUDING ATTORNEY'S FEES, RELATING TO ANY ACTION TAKEN BY THE CITY TO RECOVER SUCH AMOUNTS.
PERMITTEE SHALL REQUIRE ANY CONTRACTOR OR SUBCONTRACTOR WHO PERFORMS WORK IN OR NEAR THE PUBLIC RIGHT-OF-WAY TO HAVE OR PROCURE AND MAINTAIN BOTH COMMDRCIAL AND AUTOMOBILE LIABILITY INSURANCE
WITHOUT LIMITING THE INDEMNITY PROVISIONS OF THIS PERMIT. IF THE PROPERTY OWNER CHOOSES TO PERFORM ANY WORK IN OR NEAR THE PUBLIC RIGHT-OF-WAY ITSELF OR WITH HLEP OF OTHERS WHO ARE NOT CONTRACTORS, PROPERTY OWNER
SHALL ENSURE THAT IT HAS AND MAINTAINS ADEQUATE INSURANCE TO PROTECT AGAINST INJURIES TO PERSONS OR PROPERTY. THE EXACT FORM AND LIMITS OF THE INSURANCE SHALL BE SUBJECT TO THE APPROVAL OF THE CITY.
ALL CONSTRUCTION ACTIVITIES SHALL COMPLY WITH APPLICABLE LAWS, INCLUDING ALL APPLICABLE CITY ORDINANCES AND THE NPDES PERMIT.
I UNDERSTAND AND AGREE TO THE CONDITIONS AND REQUIREMENTS OF THIS APPLICATION FOR PERMIT
CITY OF YORB
A LINDA
PUBLIC WORKS DEPARTMENT
4845 CASA LOMA AVENUE
YORBA LINDA, CA 92886
(714) 961- 7170
TRAFFIC CONTROL PER THE LA
TEST "WATCH MANUAL" FIELD MODIFICATIONS MAY BE NECESSARY TO ENSURE TRAFFIC SAFETY AS DIRECTED BY THE CITY
ENGINEER OR CITY REPRESENTATIVE.
WORK HOURS FOR LANE CLOSURES ARE 9AM TO 3PM. OTHERWISE WORK HOURS ARE 7:30AM TO 4:30PM MONDAY THRU FRIDAY EXCEPT FEDERAL
HOLIDAYS. NO WORK REQUIRING INSPECTION IS PERMITTED IN THE CITY RIGHT-OF-WAY ON FRIDAYS WHEN THE CITY IS CLOSED. HOWEVER, FRIDAY WORK
REQUIRING INSPECTION MAY BE PERMITTED WITH ADVANCE NOTICE OF AT LEAST 48 HRS. AND PAYMENT OF A MINIMUM INSPECTION FEE.
ALL WORK SHALL CONFORM TO STANDARD SPECIFICATIONS FOR PUBLIC WORKS CONSTRUCTION, THE ORANGE COUNTY PUBLIC FACILITIES & RESOURCES DEPT.
(P.F.&R.D.) STANDARD PLANS, AND THE STANDARD SPECIFICATIONS OF THE CITY OF YORBA LINDA LATEST EDITIONS.
ASPHALT CONCRETE SHALL BE SAWCUT PRIOR TO REPLACEMENT. MINIMUM PAVEMENT SECTION SHALL MATCH EXISTING SECTION PLUS 1-INCH OF ASPHALT.
COMPACTION TEST REQUIRED BACKFILL MAY BE 1-1/2 SACK SAND SLURRY UNLESS OTHERWISE DIRECTED BY THE CITY ENGINEER. PLATES AND TEMPORARY
AC TO BE ON SITE PRIOR TO START OF WORK.
A "T" CAP WILL BE UTILIZED ON ALL STREET CUTS. "T" SHALL EXTEND A MINIMUM OF ONE (1) FOOT BEYOND EACH SIDE OF THE TRENCH. THE GRIND WIDTH WILL BE
DETERMINED BY THE LOCATION OF THE TRENCH WITHIN A LANE. THE VEHICULAR PATH OF TRAVEL AND THE TRENCH WIDTH. THE PAVEMENT SHALL BE COLD
PLANED 2 INCHES AND RESURFACED WITH 2 INCHES OF ASPHALT CONCRETE OR REPLACED IN KIND
PORTLAND CEMENT CONCRETE SHALL BE SAWDUST AND REMOVED TO EXISTING CONTROL JOINTS.
A 90% COMPACTION, VERIFIED BY TESTS, IS REQUIRED IN DIRT EXCAVATION AREA.
REPLACE EXISTING STRIPING AS DIRECTED BY THE CITY INSPECTOR. ALL DAMAGED TRAFFIC LOOPS SHALL BE REPLACED WITHIN 3-5 DAYS
CALL 48 HOURS PRIOR TO EACH DAY OF WOK UNDER THIS PERMIT FOR INSPECTION.
CALL FOR INSPECTION WHEN WORK IS COMPLETE FOR REFUND OF DEPOSIT.
SEE ATTACHED CONDITIONS.
IMPORTANT NOTICE
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