Submit Encroachment Permit (Public Works)
APPLICANT INFORMATION:
Permit #:
Application Date:
 
Job Location  
Property Owner  
Address  
City   State   ZIP  
EvaluateFormula("= \"Phone Number\"", true)               EvaluateFormula("= \"Cell Number\"", true)  
Email  
CONTRACTOR INFORMATION:
EvaluateFormula("= \"Name\"", true)     
EvaluateFormula("= \"Address\"", true)     
EvaluateFormula("= \"City\"", true)      EvaluateFormula("= \"State\"", true)      EvaluateFormula("= \"ZIP\"", true)     
EvaluateFormula("= \"Phone\"", true)      EvaluateFormula("= \"Cell Number\"", true)  
EvaluateFormula("= \"Email\"", true)     
EvaluateFormula("= \"State License
Number\"", true)
     EvaluateFormula("= \"License Class\"", true)   Exp. Date
 
EvaluateFormula("= \"Contractor City
License Number\"", true)
    
USA Ticket Number  
REFUNDABLE DEPOSIT:
EvaluateFormula("= \"Refundable Deposit
Amount\"", true)
 
EvaluateFormula("= \"Depositor\"", true)  
EvaluateFormula("= \"Address\"", true)  
EvaluateFormula("= \"City\"", true)   EvaluateFormula("= \"State\"", true)   EvaluateFormula("= \"ZIP\"", true)  
EvaluateFormula("= \"Phone Number\"", true)   EvaluateFormula("= \"Cell Number\"", true)  
EvaluateFormula("= \"Email\"", true)  
DESCRIPTION OF WORK:
Description Of Work    
ADDITIONAL INFORMATION:
EvaluateFormula("= \"Two Sets Of Construction
Plans Upload\"", true)
  EvaluateFormula("= \"Upload Construction Plans(PDF Only)\"", true)     
EvaluateFormula("= \"Two Sets Of Traffic
Plans Upload\"", true)
  EvaluateFormula("= \"Upload Traffic Plans(PDF Only)\"", true)     
CONTRACTORS PERFORMING WORK WITHIN THE PUBLIC RIGH OF WAY OTHER THAN
THE GENERAL CONTRACTOR SHALL PULL A RIDER PERMIT PRIOR TO START OF WORK.
Preferred Method Of Contact
UPLOAD REQUIRED:
*GENERAL LIABILITY INSURANCE WITH THE CITY OF DOWNEY AS
ADDITIONALLY INSURED AND CERTIFICATE HOLDER WITH APPLICABLE ENDORESEMENTS
EvaluateFormula("= \"General Liability Insurance\"", true)  
EvaluateFormula("= \"State Of California
Contractors License Pocket Card\"", true)
 
SIGNATURE:
*I UNDERSTAND AND AGREE TO THE CONDITIONS AND REQUIREMENTS OF THIS APPLICATION FOR PERMIT.
Signature Name  
Signature Date
 
EvaluateFormula("= \"Phone Number\"", true)      EvaluateFormula("= \"Cell Number\"", true)  
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