Encroachment Permit Form

Download a blank fillable Encroachment Permit Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Encroachment Permit Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Complete, save, then press Submit by Email button.
Submit by Email
EP Number PW
ENCROACHMENT PERMIT
qr batch #
s t a m p
Public Works & Utilities Department
initials
11 English Street
Utility ID #:
Email:
EncroachmentPermits@ci.petaluma.ca.us
Utility Project #:
Inspection Services
Annual Permit for
Sewer Lateral Grant Program
To reach the Inspector: 707.778.4303, option 7
Cash Bond Return $ _____________
Questions on the permitting process: 707.778.4303, option 6
Hot Tap Size ________ / Fee $ _____________
Office Hours: Monday-Thursday 8am-noon & 1pm-5pm
Please Note: Unless otherwise indicated, this permit is valid for a period of 30 days from the date of approval. Driveway
approach and sidewalk construction in a developed area must be completed within 14 days after the start of removal or
construction operations. Project plans may be required depending on scope of work. Hot tap fees are paid at submittal of permit.
Payments can be made by check to the City of Petaluma, cash for the exact amount or by credit card. (There is a 2.5% credit card fee).
Below box to be filled in by the applicant. Check all that apply.
PROJECT LOCATION:
EXCAVATION: (check as many as applicable to the proposed project)
ENCROACHMENT:
Aboveground Utility:
Underground Utility:
Installation/Repair/Replacement:
Parking Permit
Electrical
Water
Sidewalk
Dumpster/Storage Container
Telephone
Gas
Driveway
Scaffolding/Barricades
Cable TV
Electrical
Street Paving
Tree Trimming/Removal
Sewer
Curb & Gutter
Awnings
Storm Drain
Outdoor Seating Area
Misc
Telephone
Bike Racks
Cable TV
Street Furniture
Describe work to be completed:
START DATE:
COMPLETION DATE:
Contractor:
Owner:
Contact Name:
Address:
Address:
Phone:
Phone:
E-Mail:
State License #:
E-Mail:
*NOTE: MINIMUM OF 24-HOUR NOTICE REQUIRED
Bond Information:
A security bond shall be submitted with this application. See Below:
PRIOR TO WORK AND FOR ALL INSPECTION REQUESTS
Sidewalk/Driveway – Residential/Commercial
$5,000
CALL 707.778.4303, Option 7
Sewer/Water Lateral
$10,000
Other: __________________________________
$_________
*Permit will not be issued until applicant provides USA ticket number. USA Phone #: 1-800-227-2600
Excavation in Public Right-of-Way Required?
Yes
No
If “yes”, U.S.A. Ticket No.**
*Permit will not be issued until applicant provides current insurance certificates and City business license. The undersigned does
hereby agree to indemnify and hold the City of Petaluma free and harmless from any liability in accordance with Section 13.04
and 13.12, Petaluma Municipal Code.
City Business License No.:
* Current Certificates of Insurance
Date
Signature:
Owner
Contractor
Rentor
Processed By:
Date:
Date to Inspector:
Approved for Construction:
Date:
Issued By:
Date:
Issue Fee #:
Final Inspection By:
Date:
Permit Fee:
$
See Next Page for All Conditions Applicable to this Permit
S:\City Engineering\Inspection Division\Encroachment Permits\Encroachment Permit Forms\Encroachment Permit Form (08-05-15).Doc

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 2