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CITY OF LONG BEACH
Revision Date: May 2019
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 OR bring all items in
electronic format (USB drive) to the public counter at City Hall, 411 W Ocean Blvd, 2nd Floor, Long Beach 90802. All drawings shall be a
minimum of 1 to 40 engineering scale. Bring a check payable to the City of Long Beach to the public counter, pay the appropriate fees, and
provide payment receipt to the permit technician. The plan check process will NOT begin until after payment if confirmed.
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
CITY
STATE
ZIP CODE
FRANCHISE AND/OR MASTER AGREEMENT NUMBER (IF APPLICABLE)
DESCRIPTION OF PROJECT/ REASON FOR APPLICATION
OWNERS 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 OWNERS BEHALF)
☐ DESIGNER ☐ OWNERS AGENT ☐ LESSEE/TENANT ☐ CONTRACTOR ☐ OTHER:
APPLICANTS BUSINESS NAME/DBA
PHONE NUMBER
CITY
STATE
ZIP CODE
CITY OF LONG BEACH
Revision Date: May 2019
Page 2
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
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)
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)
ADD
ITIONAL 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
Parcel/ Tract Map on City Template
Engineer’s estimates for the performance, labor, and materials bonds
Performance, 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
FEE (Office Use)
$
6.2% SURCHARGE
$
TOTAL FEE
$
CITY OF LONG BEACH
Revision Date: May 2019
Page 3
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
OWNER NAME
PHONE NUMBER
EMAIL ADDRESS
ADDRESS
CITY
STATE
ZIP CODE
ADDITIONAL CONTACT/SITE CONTACT NAME
PHONE NUMBER
*NOTE: The names listed on the STATE LICENSE, CITY LICENSE and INSURANCE POLICY must be identical. Include a copy of
the insurance policy AND the completed City endorsement form with this application.
ITEMS THAT MUST ACCOMPANY THIS APPLICATION
☐ Construction schedule
☐ List of subcontractors and applicable contractors license
☐ Contractors Insurance Certificate
☐ Completed City Insurance Endorsement Form
☐ Statement of approximate value for work within the right of way/ park
NO
TE: 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.
CITY OF LONG BEACH
Revision Date: May 2019
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
temporary encroachments within the ROW of less than 90
days. Examples include; utilizing a parking stall for material
deliveries, laydown, storage of equipment, dumpster, 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 City Standard Plan
Closure of residential driveway City Standard Plan
Installation of ADA ramp City Standard Plan
Replacement of curb and gutter less than 50 linear feet City Standard Plan
Replacement or Installation of sidewalk less than 50 linear feet Standard Plan for Public Construction
Install, and/or trim street trees in front of residence Muni Code
Installation of mailboxes, news racks, & benches City Standard Plan
Occupancy of 1-2 parking stalls (dumpster, pod, laydown) City Standard Plan
Residential sewer/ water repair as approved by LBWD Long Beach Water Department
Window Washing
Other activity using ROW for less than 90 days
ITEMS THAT MUST ACCOMPANY THIS APPLICATION
ITEMS THAT MUST ACCOMPANY ALL APPLICATIONS
☐ Site plan/ staging drawings clearly identifying total area (in square feet) of ROW being used/ occupied
☐ Photos of existing conditions of the area
☐ Details of the installation/ work being completed
☐ Traffic control drawings (if working within roadway)
☐ Caltrans approval (if work is in PCH or State Route 22)
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 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
$
CITY OF LONG BEACH
Revision Date: May 2019
Page 5
C – RIGHT OF WAY OCCUPANCY/
EXCAVATION
Complete this section ONLY IF:
- your project includes excavation on private property 3’ or
more below grade
- excavation within the ROW 10” or more below grade
- occupancy of the ROW for more than 90 days.
This including: trenching, staging, fencing, monitoring wells, soil
borings, Not required for PWOP or WTF.
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
ITEMS THAT MUST ACCOMPANY ALL APPLICATIONS FOR OCCUPANCY, EXCAVATION, GRADING,
TRENCHING, UTILITY TIE IN, AND MONITORING WELLS
☐ Notice of Final Action and Conditions of Approval (if applicable)
☐ Site plan drawings (this must clearly identify any meters being impacted)
☐ Staging drawings clearly identifying total area (in square feet) of ROW being occupied
☐ Traffic control drawings (if in the roadway)
☐ Pedestrian protection drawings (if occupying sidewalk)
☐ Scaffolding plan and engineering calculations (if within ROW)
☐ Caltrans approval (if work is in PCH or State Route 22)
☐ Graphic fence wrap for temporary fencing (if project is longer than 6 months)
ADDITIONAL ITEMS THAT MUST ACCOMPANY EXCAVATION, GRADING WORK
☐ Excavation drawings (if excavation is greater than 3’deep)
☐ Haul route plan (if hauling spoils)
☐ Hydrology report (if applicable)
☐ Dewatering report (if applicable)
☐ Geotechnical report (if applicable)
☐ Shoring plans (if excavation is greater than 5’deep)
☐ Tie back agreement (if applicable)
ADD
ITIONAL ITEMS THAT MUST ACCOMPANY TRENCHING, 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…)
ADD
ITIONAL 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
FEE (Office Use)
$
6.2% SURCHARGE
$
TOTAL FEE
$
CITY OF LONG BEACH
Revision Date: May 2019
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
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
☐ Submit a copy of the previously issued permit(s)
☐ Yes, but there are some changes to the previously approved items
☐ Submit a copy of the previously issued permit(s)
☐ Submit all applicable documents to verify the changes
☐ 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)
☐ Engineers estimate for the ROW improvements
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
$
CITY OF LONG BEACH
Revision Date: May 2019
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)
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 liability certificate of 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 PARKLET APPLICATION
Detail drawings of the platform and barricade stamped by a CA registered engineer
Letter of approval from homeowner’s association (HOA) OR community association (If No HOA)
Location of relocated parking meters (if applicable)
Traffic control drawings
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 liability certificate of insurance. Liquor liability must be included 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
$
CITY OF LONG BEACH
Revision Date: May 2019
Page 8
F – WIRELESS
TELECOMMUNICATION FACILITY
Complete this section ONLY IF your project includes
installation of a wireless telecommunications facility
Type of Permit applying for: Tier A (Unprotected) Tier B (Protected) 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
Copy of the Long Beach master license agreement (LBMC Chapter 15.34.030.B.1.b.x.8-9)
Signed letter on CPUC Franchise Entity letterhead authorizing the applicant to act on behalf of the franchise.
Letter must include:
• Franchise name, address, contact phone and contact email address
• Franchise entity CPUC license number
• Authorized applicant firm name, address, contact phone and contact email address
• Authorized applicant’s limits of responsibility
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)
Traffic control drawings (as applicable) (LBMC 15.34.030.D.12 and LBMC 14.14.040.E)
Landscape drawings (if applicable) (LBMC Chapter 21.56.100.A.5)
Street tree plan (if applicable) (LBMC 15.34.030.G)
CALTrans approval (if work is in PCH or State Route 22)
Radio frequency engineering report (LBMC 15.34.030.D.7)
Noise analysis (manufactures specifications acceptable) (LBMC 15.34.030.D.14)
GIS map (Electronic) showing underground conduit runs (LBMC 15.34.030.D.4)
GIS map (Hardcopy) showing underground conduit runs (LBMC 15.34.030.D.4)
Photos of existing conditions of the area (LBMC 15.34.030.D.5)
Photo simulation of proposed project (LBMC 15.34.030.D.12)
Maintenance plan (LBMC 21.56.050.B and LBMC 15.34.030.B.1.b.7.i)
Joint pole commission approval letter for wooden poles only (LBMC 15.34.030.B.1.b.ii)
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)
Propagation/Coverage Maps (if denial would cause a “significant coverage gap”) (LBMC 15.34.030.D.6)
Completed antenna, equipment and site location preference form (see following page) (LBMC 15.34.030.B.1.b.vi)
ADDITIONAL ITEMS THAT MUST ACCOMPANY A TIER B (PROTECTED LOCATION) APPLICATION
Letter explaining the installation will not significantly detract from any defining characteristics of the area or the
view corridor (LBMC 15.34.020.Z)
Confirmation of public notification incuding notice by mail and notice by posting (LBMC Chapter 15.34.030.K.1-3)
FEE (Office Use)
$
6.2% SURCHARGE
$
TOTAL FEE
$
CITY OF LONG BEACH
Revision Date: May 2019
Page 9
Per
LBMC 15.34.030.B. 1.b.vi Aesthetic Impacts, all wireless telecommunication facilities shall be designed and located
to eliminate 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
CITY OF LONG BEACH
Revision Date: May 2019
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)
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Completed 14 July 2020

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