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