APPENDIX D ENCROACHMENT APPLICATION.PDF

APPENDIX D

R-O-W ENCROACHMENT PERMIT APPLICATION

T:\FORMS & APPLICATIONS\ENCROACHMENT APPLICATION 6/6/17 TA

Right-of-Way Encroachment Application

CITY of CHINO

Public Works Department 13220 Central Avenue

Chino, CA 91710

(909) 334-3265 www.cityofchino.org

Applicant (Company Name): Contact Person:

Applicant Address:

Phone No.: E-Mail Address:

Contractor: Contact Person:

Contractor Address:

Phone No.: Email Address:

Certificate of Insurance Policy No.: Expiration Date:

Contractor’s State License Board No.: Expiration Date:

City of Chino Business License No.: Expiration Date:

WORK TO BE PERFORMED

Domestic Water Paving Striping Curb Core Sidewalk

Drive Approach Storm Drain Curb & Gutter Sewer Traffic Signal

Recycled Water Grading Street Lights Communication/Fiber

Optic

Electrical

Gas Bag/Unbag Signs CCTV Inspections Traffic Signal Interconnect Pothole/Coring

Wall/Fence in ROW Sign in ROW Newsrack Open/Close Gates Pool/Spa

Hauling Other

Lane Sidewalk/Parkway Shoulder Whole Roadway (Full Street) Detour

WORK WILL REQUIRE CLOSURE OF THE FOLLOWING (CHECK ALL THAT APPLY)

PROJECT INFORMATION

STREET LIMIT OF ROADWAY AFFECTED START DATE: END DATE:

TO

TO

TO

TRAFFIC CONTROL TO BE SET PER:

W.A.T.C.H. MANUAL MUTCD CJUTCM TRAFFIC CONTROL PLAN REVIEWED ON:

Work Location: Project Number:

24-Hour Emergency Contact #1 24-Hour Emergency Contact #2

Name: Name:

Phone No.: Phone No.:

Sample application only. Contractor to apply using the City's Accela online program.

T:\FORMS & APPLICATIONS\ENCROACHMENT APPLICATION 6/6/17 TA

Staff Use Only

Received by Date

COMPLIANCE NOTE

“I hereby apply for an Encroachment Permit pursuant to the provisions of Chapter 12.02 of the Chino Munici-pal Code. I have received and read Chapter 12.02 of the Chino Municipal Code and I understand the requirements imposed upon me or my company and my agents, employees, contractors and suppliers. I understand that any vio-lation of Chapter 12.02 may result in the issuance of a “Demand for Compliance” requiring me to comply with Chap-ter 12.02 and the directive of the Director of Public Works within 24 hours, unless I am able to satisfy said Director that such compliance is not required. I further understand that any violation of Chapter 12.02 may result in the is-suance of a “Stop Work Order” requiring my project to be halted for an unspecified period of time and the suspen-sion or revocation of any other permit issued to me by the City of Chino for this project (including any building per-mit). I further understand that any violation of Chapter 12.02 or the terms or conditions of the encroachment permit constitutes a misdemeanor. Finally, I understand and agree to compensate the City of Chino and any other party for all costs to restore any and all damage to the public right-of-way, other city property, and other life or property, and for all remediation costs of all environmental damage caused, directly or indirectly, by my acts or omissions as re-quired by Chapter 12.02 of the Chino Municipal Code.”

It is agreed that the applicant shall indemnify, defend, and hold City, its officers, employees and agents harmless from and against any and all claims that arise out of, pertain to, or relate to any accident, loss or damage to persons or property, happening or occurring as the result of any of the work performed under the terms of this application and the permit or permits which may be granted in response thereto, and that all said liabilities are here-by assumed by the applicant.

The above individual is authorized to control the work and to accept any “Demand of Compliance” or “Stop Work Order” and is legally required to check for underground utilities before excavating. Call Underground Service Alert at 1-800-422-4133 at least 48 hours prior to excavating.

Signature of Applicant or Representative Date

SUBMITTAL REQUIREMENTS

Provide one (1) set of plans, specifications and/or drawings.

Contractor must provide Certificate of Insurance listing the City of Chino as the certificate holder and as an additionally insured.

Contractor(s) must have a current City of Chino Business License.

Letter of Authorization from applicant if pulling permits on behalf of another entity/company.

A Sub-Contractor’s List form will be required if there will be multiple contractors working on behalf of another entity/company.

Applicant shall provide traffic plans for review. If plans are designed, they must be prepared, stamped and signed by an approved qualified registered Civil or Traffic Engineer.

Be advised, the City may ask for additional information to process your permit. Which may include:

Engineer’s Cost Estimate for all work in Chino’s Right-of-Way.

Electronic copies of approved drawings.

A detailed construction schedule/phasing plan.

Copies of approved permits from adjacent agency(ies) affected.

Material submittals.

If scope of work of original permit changes, a modification will be required. Plans and Cost Estimate will be required before work can proceed. Allow for time to review plans and amendment of permit.

Application is not complete until all required attachments are included in permit submittal