CITY OF REDONDO BEACH
PUBLIC WORKS DEPARTMENT - ENGINEERING SERVICES DIVISION
ENGINEERING PERMIT
PERMITTEE PERMIT NO.
E - 2726
NAME: • PAYER
RECEIPT NO.
ADDRESS:
CITY:_ ZIP: PROJECT ADDRESS:
HOME PHONE: (_ WORK PHONE: (____)
CITY BUSINESS LICENSE: _ EXPIRES: _ ATTACHMENTS TO ORIGINAL
COPY EXPIRES
CONTRACTOR PERMITTEE'S CA ID
CONTRACTOR'S CA ID
I, THE UNDERSIGNED, HEREBY DECLARE THAT I AM A CONTRACTOR LICENSED UNDER THE CONTRACTOR'S STATE LICENSE ID PROVISIONS OF SECTION 7000, CHAPTER 9, DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,
AND THAT MY LICENSE, LISTED BELOW, IS AND WILL REMAIN IN FULL FORCE AND EFFECT FOR THE INSURANCE CERTIFICATE TERM OF THIS PERMIT.
OTHER:
NAME: _ _ O PAYER COPY
ADDRESS: WATER QUALITY FORMS
PERMIT GUIDELINES
CITY: ZIP:_ SIGNATURE AUTHORIZATION
PLANS
BUSINESS PHONE: ( __). 24 HR. PHONE: ( -).
STATE LICENSE NO: CLASS: _ EXPIRES: _
FEES, DEPOSIT, AND BOND
CITY BUSINESS LICENSE: EXPIRES: — PERMIT FEE
INSPECTION FEE
PERMIT TYPE OTHER:
TOTAL FEES
WORK WITHIN THE PUBLIC RIGHT-OF-WAY
• ROAD • SEWER • DRAINAGE • ENCROACHMENT CASH DEPOSIT
DEDUCTION
• DUMPSTER • WELL • NEWS RACK • AGREEMENT
TOTAL REFUND
• UTILITIES • BANNER • OTHER
WORK DESCRIPTION: PERFORMANCE BOND NO.
WORK WITHIN PRIVATE PROPERTY
INSPECTION RECORD
• GRADING • DEMOLITION • SANDBLASTING • OTHER
1. WORK DESCRIPTION:
2._
WE, THE PERMITTEE AND THE CONTRACTOR, INDIVIDUALLY AND COLLECTIVELY, HEREBY
ACKNOWLEDGE THAT WE HAVE READ THIS APPLICATION, AND STATE THAT THE INFORMATION THAT WE HAVE GIVEN ABOVE, IS CORRECT. WE, THE PERMITTEE AND THE CONTRACTOR, INDIVIDUALLY AND COLLECTIVELY, UNDERSTAND THAT THE WORK DESCRIBED ABOVE WILL BE PERFORMED STRICTLY BY • CONCRETE CLASS REPORT ASPHALT CLASS REPORT THE ABOVE LISTED CONTRACTOR. WE, THE PERMITTEE AND THE CONTRACTOR, INDIVIDUALLY AND COLLECTIVELY, HEREBY AGREE TO COMPLY WITH ALL APPLICABLE FEDERAL, STATE AND LOCAL • COMPACTION REPORT LAWS, RULES AND REGULATIONS, INCLUDING THE ATTACHED GUIDELINES OF THIS PERMIT. • OTHER: _ SIGNATURE OF PERMITTEE • FINAL INSPECTION
OR AUTHORIZED AGENT: DATE: _
SIGNATURE OF CONTRACTOR INSPECTED BY:_ _DATE:_
OR AUTHORIZED AGENT: DATE: _
RELEASED BY: _ DATE: _
ISSUED BY: DATE:_
DISTRIBUTION: ORIGINAL: ENGINEERING CANARY: FINANCIAL SERVICES PINK: PERMITTEE GOLD: CONTRACTOR XEROX:_