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Rev. 11/2020 APPLICATION FOR ENCROACHMENT/GRADING/LANDSCAPE PERMIT Applicant Mailing Address Telephone No. Emergency No. Start Date(est.) Completion Date(est.) Anticipated No. of Work Days State Lic. No. Lic. Class Bus. Lic. No. Insurance Cert. Is: On File Attached Construction Location* Purpose Improvement Plan No. Construction/Excavation Item Length Width_ Residential Driveway Commercial Driveway Curb and Gutter Sidewalk Trenching: 1. Dirt 2. AC Pavement Cut Other Contractor: Address: Phone # Contractor License # CONTRACTOR INFORMATION APPLICANTS DECLARATION Application is hereby made to encroach into the public right-of-way at the above-described location(s), subject to all applicable provisions of the Highway Permit Ordinance as set forth in Chapter 12.08 of Title 12 of the Palmdale Municipal Code and any attachments hereto. Unless waived by the Assistant Director of Public Works/City Engineer, Applicant shall provide to the Engineering Division a computerized final map (in .dwg format) of the project that is compatible with the City of Palmdale’s G.I.S. program. The final map shall be projected in NAD 83 State Plane Coordinates, Zone 5 (in feet). In consideration of the granting of this permit, the applicant agrees to indemnify the City of Palmdale, its officers, employees, agents and elected and appointed boards, and to comply with the insurance requirements, as more fully set forth in paragraphs 16 and 17 on the backside of this Application. Applicant further agrees that, if any part of the work or installation authorized hereunder interferes with the future use of the highway by the general public or is necessary to facilitate any public purpose or any city project, it shall be removed or relocated, as directed by the Assistant Director of Public Works/City Engineer, at the expense of the Applicant or the Applicant’s successors or assigns unless the Applicant has an easement superior to that of the City of Palmdale at the time of this application and can furnish evidence, when required, of such superior easement. Applicant is obligated to comply with the Rules and Regulations of the Encroachment Permit found on the back of the permit. Please email the application back to [EMAIL REDACTED]. Signature of Applicant: Date: Print ---PAGE BREAK--- Rev. 11/2020 GENERAL PERMIT RULES AND REGULATIONS 1. Authority: This permit is issued pursuant to Chapter 12.08 of Title 12 of the Palmdale Municipal Code. 2. Standards: All work shall be performed in accordance with the latest edition of the Standard Specifications for Public Works Construction and other City of Palmdale standards and requirements. 3. Acceptance of Provisions: Applicant agrees that the performance of any work under this permit shall constitute an acceptance by the Applicant of all provisions hereof. 4. Notice Prior to Starting Work: Prior to starting any work authorized herein. Applicant shall provide at least one working day’s notice to the City of Palmdale Engineering Division for initial inspection and any subsequent inspection. 5. Traffic Control: All traffic control devices and layouts shall conform to the latest edition of the California Manual of Uniform Traffic Control Devices. Applicant shall submit, for City review, an engineered traffic control plan when the proposed construction work involves any of the following conditions: Moving traffic over the street centerline, Reducing the number of travel lanes by more than one lane, Any road closure (one or two-way), Any work performed within 250 feet of a traffic signal. In addition, at the discretion of the Assistant Director of Public Works/City Engineer, an engineered traffic control plan may be required for other work impacting the public right-of-way. The applicant is solely responsible for the traffic control design and implementation. Furthermore, the applicant is responsible for maintaining the approved traffic control plan for the construction zone, on a 24-hours basis. The traffic control plan shall remain in place until work is completed. Any street closure will require the approval of the Assistant Director of Public Works/City Engineer. 6. Work Site: This permit shall be kept at the work site and, upon request, must be shown to any representative of the Development Services, Engineering Division or any law enforcement officer. Applicant shall be responsible for keeping the work site safe. Applicant shall monitor the work site 24 hours a day and regularly inspect any and all barricades, signs, traffic control measures, warning devices, materials, and vehicles to ensure the safety of workers and the general public. 7. Access to Fire Hydrants and Adjacent Property: Access to fire hydrants shall be maintained at all times. Access to adjacent property shall be provided as directed by the Assistant Director of Public Works/City Engineer. 8. Permits for Other Agencies: Applicant must obtain all other permits required by other public or private agencies or individuals necessary in order to perform the intended work. If this provision is not complied with, this permit shall be null and void. It shall be the responsibility of the Applicant to notify all of the impacted entities including the utility and cable TV companies prior to starting any construction that may involve their underground or overhead facilities. 9. Underground Service Alert: Applicant must notify Underground Service Alert (USA) at [PHONE REDACTED] at least 48 hours in advance of start of work for location of underground utilities. 10. Clean-up Right-of-Way: Upon completion or work, all brush, timber, scraps and other materials and debris shall be entirely removed and the right-of-way left in a condition satisfactory to the Assistant Director of Public Works/City Engineer. 11. Construction and Repair: Applicant shall properly construct, maintain and repair any encroachment authorized herein, and shall exercise reasonable care in inspecting and immediately repairing any damage to the public right-of-way and underlying utilities which occurs as a result of said encroachment or as the result of any work done hereunder. 12. Notification to Property Owners: Applicant shall notify abutting property owners affected by this encroachment prior to starting any work hereunder. 13. Maintenance and Repair: Applicant shall make any and all repairs to public right-of-way if required by the Assistant Director of Public Works/City Engineer. Time for completion of said repairs shall be as required by the Assistant Director of Public Works/City Engineer. The Applicant is responsible for the materials and workmanship of this encroachment for duration of this permit. 14. Inspection Prior to Placement: Applicant shall request inspection of conduit installation and corrections and repairs made to existing underground utilities prior to backfilling. Concrete forms shall be inspected prior to placement of concrete. 15. Storage of Materials: Absolutely no stockpiling of material will be allowed in the street or sidewalk area unless authorized by this permit. 16. Liability of Damages: To the fullest extent permitted by law, Applicant and any contractors or subcontractors working on its behalf agree to indemnify the City of Palmdale, its officers, employees, agents and elected and appointed boards (hereinafter “City”) for any loss, claim, demand, cause of action, cost, expense, damage, obligation or liability which arises out of or is in any way connected with the performance of any work under the permit, including any acts or omissions, willful misconduct or negligent conduct, whether active or passive, on the part of Applicant, its contractors or subcontractors, and regardless of any acts, omissions or negligence (whether active or passive) of any person or entity indemnified hereunder. At their own expense, Applicant and, as applicable, any contractors or subcontractors working on its behalf, shall defend any suit, claim or action against the City founded upon such loss, claim, demand, cause of action, cost, expense, damage, obligation or liability. Applicant shall ensure that the contract of any contractor or subcontractor working under this permit contain an indemnity agreement, requiring the contractor or subcontractor to indemnify and defend the City pursuant the terms set forth above. Applicant shall indemnify the City, and save it harmless from any and all loss, damage, costs, expenses and attorney's fees suffered or incurred on account of any breach of the aforesaid obligations and covenants, and any other provision or covenant of this application. 17. Liability Insurance (revised 11/2020): Grading: Minimum of $1 million OCC/$2 million AGG Encroachment Only: Minimum of $1 million OCC/$2 million AGG Encroachment with Opening of Right of Way: minimum of $2 million OCC/$4 million AGG *The City must be included as additional insured and the endorsement must be attached* *See insurance matrix for additional information* 18. Revocation of Permit: This permit may be terminated by the Assistant Director of Public Works/City Engineer upon 30 day’s written notice. 19. Inspections: Call the office of the City Engineering Inspection Hotline at (661) 267-5255, 24 hours prior to all inspections.