Engineering and Transportation

ENGINEERING AND TRANSPORTATION

CURRENT DEVELOPMENT

APPLICATION FOR ENCROACHMENT PERMIT

JOB ADDRESS (STREET AND NAME) /

PROJECT

/ DATE
PERMITTEE NAME / WORK ORDER #
MAILING ADDRESS CITY ZIP / PERMITEE TELEPHONE
CONTRACTOR NAME / CONTRACTOR TELEPHONE
ADDRESS CITY ZIP / STATE CONTRACTOR’S LICENSE # / CITY BUSINESS LICENSE #
APPROX. STARTING DATE / APPROX. COMPLETION DATE / JOB SITE / TELEPHONE
DATE / PLANS ATTACHED: (CIRCLE ONE) YES NO
DESCRIPTION OF WORK / IF YES IS CHECKED, REFER TO PLANS:
(PLAN TITLE, USE PERMIT #, SUBDIV. #, ETC) IF NO IS CHECKED ATTACH 3 COPIES OF PLANS FOR WORK TO BE DONE
ITEM / EACH / QUANTITY / TOTAL
FILING FEE / $47.00 / $47.00
PLAN CHECK FEE / $94/HR
MAJOR CONSTRUCTION / 9% OF CONST. COST
CURB & GUTTER SIDEWALK SEWER LATERAL / $118 MIN.
HOUSE MOVE / $376.00
PLACEMENT OF MATERIALS / $13.40 per day
REINSPECTION FEE / $94/HR
MISCELLANEOUS / $94/HR
DRIVEWAY / $282 MIN. OR $94/HR ABOVE MIN.
TOTAL
NOTES 1. Inspections may be requested by notifying the Engineering Department at (925) 671-3443. Twenty-four (24) hours notice is required in order to schedule inspection. 2. Any person, firm or corporation encroaching into the public right-of-way, or water course to do work, store materials, erect or place any structure is required to obtain an Encroachment Permit and such activity is covered under ARTICLE VII. CHAPTER 2 of the CONCORD MUNICIPAL CODE.

DATE

APPROVED BY

FINANCE CODE

PERMIT NUMBER

CERTIFICATE OF INSURANCE AND LICENSE COMPLIANCE

CMC Section 7214.I. Each person or entity prior to the granting of an encroachment permit shall furnish to the City a certificate showing that such person or entity has then in force a policy of commercial general liability insurance naming the City as an additional insured in the amount of not less the One Million Dollars ($1,000,000) per person or per occurrence combined single limit.

DIRECTIONS: Place an “X” next to the appropriate statement under both the Workers’ Compensation section and the Contractor’s Licensing section below. Fill in any blanks in the statement where your “X” is. Sign and date this form after you have read everything on it.

WORKERS’ COMPENSATION (Labor Code Section 3800)

1. a. I have attached a certificate of insurance which shows that I carry workers’ compensation insurance for work to be done under this permit.

 b. I have on file with the Concord Building Division a certificate of insurance as described in (a) above.

2. I have attached a certificate of consent to self-insure issued by the Director of Industrial Relations.

3. I certify 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 become subject of the workers’ compensation laws of California.

CONTRACTOR’S LICENSING (Business and Professions Code Section 7031.5)

1, As the applicant, I am licensed under the provisions of the Contractor’s License Law. My license number ______in classification ______is in full force and effect.

2. I am exempt from the “License Required” provisions of the Contractor’s License Law. State basis of exemption: ______.

I understand that this permit is automatically revoked at any time when I am required to have workers’ compensation insurance but do not. I agree to indemnify and hold harmless the City of Concord against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of granting this permit.

SIGNATURE OF PERMITTEE OR PERSON DATE
AUTHORIZED TO SIGN FOR PERMITTEE

City of Concord1950 Parkside DriveM/S 52Concord, CA 94519(925) 671-3425FAX (925) 671-3203