ANNUAL UTILITY BLANKET PERMIT APPLICATION

Transcription

1 CITY OF BEVERLY HILLS COMMUNITY DEVELOPMENT DEPARTMENT 455 NORTH REXFORD DRIVE BEVERLY HILLS, CA (310) ANNUAL UTILITY BLANKET PERMIT APPLICATION PERMITTEE INFORMATION Utility Company Name: Address: Authorized Representative: Cell Phone: Work Permit Location: Permit Period From: To: January 31, 20 PERMITTEE CERTIFICATION I HEREBY ACKNOWLEDGE THAT I AM A DESIGNATED REPRESENTATIVE OF MY UTILITY COMPANY WITH THE AUTHORITY TO SIGN BINDING CONTRACTUAL DOCUMENTS AND THAT I HAVE READ THIS PERMIT AND STATE THAT THE INFORMATION GIVEN IS CORRECT, AND AGREE TO COMPLY WITH ALL APPLICABLE CITY, STATE AND FEDERAL LAWS PERTINENT TO THE REQUIREMENTS OF THIS BLANKET PERMIT INCLUDING THE ATTACHED ANNUAL UTILITY BLANKET PERMIT REQUIREMENTS. I HEREBY ACKNOWLEDGE THAT MY UTILITY COMPANY UNDERSTANDS AND WILL COMPLY WITH THE PERMIT REQUIREMENTS, RESTRICTED AREAS MAP, AND CONDITIONS OF APPROVALS. Permittee Authorized Representative Name: Permittee Title: Signature: Date: THIS PERMIT OR AUTHORIZED COPY MUST BE AVAILABLE AT THE WORK ACTIVITY SITE FOR REVIEW BY ANY AUTHORIZED CITY PERSONNEL. CITY APPROVAL Approved by: Date: Printed Name/Title:

2 CITY OF BEVERLY HILLS COMMUNITY DEVELOPMENT DEPARTMENT 455 NORTH REXFORD DRIVE BEVERLY HILLS, CA (310) ANNUAL BLANKET UTILITY PERMITS WORK START DATE: WORK ACTIVITY NOTICE (WAN) WORK END DATE: Blanket Permit No. RESTORATION DATE: Utility Company/Contractor: APPLICANT INFORMATION Contact Name: Address: Office Phone: Mobile Phone: Jobsite Address: Work Description: SITE INFORMATION Estimated No. of Days: Type of use (check all that apply): Alley Parking lane/lot Parkway Sidewalk Travel lane Approved Traffic Control Plan: TTCP No. Rev. No. Posted Parking Description (list meter numbers if applicable): Number of No Parking Signs required: (metered spaces must be paid in advance) Location of Excavation: EXCAVATION INFORMATION Dimensions of Excavation: Length Width Depth Underground Utility Alert (USA) Ticket No.: completed Work Activity Notice form to: three (3) business days prior to beginning work in the public wright of way. Site Foreman/Superintendent must notify Public Works staff at (310) on first day of work (prior to beginning work activities). Must complete steps in second page. 1

3 TERMS AND CONDITIONS I have read and understood all of the terms and conditions as specified in the Annual Blanket Permit Requirements. All impacted residents have been notified of the planned work. By issuance of this permit and the exercise by permittee of the rights granted by the permit, permittee agrees to indemnify, defend, and hold harmless the City of Beverly Hills, its City Council, Boards or Commissions, officers, agents, or employees from any claim, liability, or damage arising out of or resulting from the permittee's exercise of the rights granted by the permit. By checking the box, the applicant agrees to abide by all requirements of the Beverly Hills Municipal Code and conditions set forth on the permit. Failure to comply may result in permit revocation and/or civil penalties. A check in this box will be equivalent to a signed application. Signed: Print Name: Date: (Not necessary for electronic submissions) 2

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14 TOWER RD COPLEY PL LAUREL WY LASKY DR N LA PEER DR FOOTHILL RD N SWALL DR N CLARK DR N HAMEL DR S LA CIENEGA BLVD Restricted Work Areas from Annual Blanket Utility Permit EVELYN PL LOMA VISTA DR Restricted Areas* Streets Alleys Adjacent to Commercial and Mix Land Uses Downtown Commercial Area *Designated areas require separate utility permit application submittal. COLDWATER CANYON DR CARLA RDGE ARKELL DR LESLIE LN USHER PL BURK PL COLE PL CHALETTE DR ALEXIS PL Ü CARLA LN WALLACE RDGE N HILLCREST RD DRURY LN BENEDICT CANYON DR SAN YSIDRO DR SUMMIT DR MARILYN DR WOODLAND DR CALLE VISTA DR LA ALTURA RD SCHUYLER RD ROBERT LN DOHENY RD N ALTA DR PHYLLIS ST CINTHIA ST ANGELO DR PAMELA DR COVE WY ELDEN WY LEXINGTON RD HARTFORD WY SUNSET BLVD LOMITAS AV N FOOTHILL RD N ARDEN DR N HILLCREST RD N ALTA DR N SIERRA DR N OAKHURST DR N DOHENY DR West Hollywood LADERA DR N ELM DR N MAPLE DR N PALM DR CIVIC CENTER DR WHITTIER DR CARMELITA AV N ALPINE DR CIVIC CENTER DR BEVERLY BLVD ALDEN DR Los Angeles ELEVADO AV N BEDFORD DR N LINDEN DR WALDEN DR S SANTA MONICA BLVD SANTA MONICA BLVD DURANT DR MORENO DR S SPALDING DR S SHIRLEY PL N ROXBURY DR S LINDEN DR S MCCARTY DR S ROXBURY DR PARK WY N CAMDEN DR S BEDFORD DR S PECK DR N RODEO DR N BEVERLY DR S CAMDEN DR S RODEO DR VIRGINIA PL N CANON DR N REXFORD DR N CRESCENT DR WILSHIRE BLVD S EL CAMINO DR S BEVERLY DR BEVERWIL DR S REEVES DR FOOTHILL RD S ELM DR CHARLEVILLE BLVD S CANON DR S CRESCENT DR W 3RD ST BURTON WY N ELM DR S REXFORD DR N MAPLE DR S MAPLE DR N PALM DR DAYTON WY S PALM DR N OAKHURST DR S OAKHURST DR N DOHENY DR S DOHENY DR N WETHERLY DR S WETHERLY DR W OLYMPIC BLVD WHITWORTH DR N ALMONT DR GREGORY WY S ALMONT DR S LA PEER DR S SWALL DR S CLARK DR N ROBERTSON BLVD S ROBERTSON BLVD N ARNAZ DR S ARNAZ DR S HAMEL DR S WILLAMAN DR CLIFTON WY GREGORY WY S CARSON RD N CARSON RD N STANLEY DR S STANLEY DR N LE DOUX RD S LE DOUX RD S LE DOUX RD N LA CIENEGA BLVD N HAMILTON DR S HAMILTON DR SAN VICENTE BLVD N GALE DR S GALE DR TOWER DR HEATH AV 0 1 Miles This map is tentative and may change at any time. The City of Beverly Hills makes no representations or warranties of any kind with respect to the accuracy of the information or data furnished herein. 03/2017