HomeMy WebLinkAbout0850-72_Baseline Avenue/Almeria Avenue - Sewer Project_11.3STATE OF CAUFORNIA • DEPARTMENT OF TRANSPORTATION
STANDARD ENCROACHMENT PERMIT APPLICATION
TR 0100 (REV. 3/92)
Pogo 1.
Front
FOR CALTRANS USE
Permission is requested to encroach on the State Highway Right of Way
as follows: (Complete ell items: NA if not applicable.
Application is not complete until all required attachments are included.
PERMIT NO.
DIST/COrRTE/PM
1. BR AT1ON: CITY
Fontana
2. COUNTY
San Bernardino
3. ROUTE
66
SIMPLEX STAMP
.
4. POST MILE
S. APPLICATION DATE
. 04-30.-93
S. ADDRESS OR STREET NAME
Foothill
7. CROSS STREET (District end arseaon from site)
From Cherry to Citrus
L PORTION OF RIGHT OF WAY
DATE OF SIMPLEX STAMP
I. WORK TO BE PERFORMED
BY
in CONTRACTOR
10. EST. START DATE
05-14-93
11. EST. COMPLETION DATE
07-18-93
12. EST. COST IN STATE R/W
3 OYN.FORCES
EXCAVATION
11 MAX. DEPTH
11. AVG. DEPTH
1L AVG. WIDTH
IS. LENGTH
17. SURFACE TYPE
PPES
11. TYPE
IS. DIAMETER
20. VOLTAGE / PSIG
21. PRODUCT
22. FULLY DESCRIBE WORK WITHIN STATE R/W: Attach complete plans (minimum S sets folded 8 Wax 11), specs, ryes, maps, etc., it applicable.
Place temporary construction detour signs per attached plans on Foothill Boulevard
(Route 66)
23. Is any work being dons on applicant's property? (If YES' , briefly describe and attach site and grading plans.) El YES 0 NO
XIS A OTT. COUNTY CO °TWA AGENCY INVOLVED IN EMVMOIBRAL APPROVAL?
❑ YES PHA documentation typo and Mach approved my)
® NO (Chock the oalapaT baking trtkirlt demists the peaSal)
❑ SURVEY 0 FENCE 0 PARADES. CELBFIAT10NS
❑ FLAGS. SIGNS. BMIERS. 0 S AMLY DWELLING MW
❑ COMNMI TY AEA TV SYSTEM
0 EROSION CONTROL
❑ TEMPORARY SEPALS ❑ REMOVAL -REPLACEMENT OF
DISTINCTIVE ROADWAY MARKINGS 0 AGROULTUJRAL APPROACH
® EXEMPT ❑ N.D. ❑ Eet
❑ PUBLC UTLtTY YOOFICATIONS, 0 DITCH PAVING 0 MMiTENANCE. RECONSTRUCTION. OR
EXTENSIONS.� RESURFACIO OF A DRIVEWAY OR ROAD
❑ SIEWALX / GUTTERS 0 MAILBOX APPROACH
❑ NONE OF THE ABOVE d p4os camas be doanOM in oeorr, ...I.,. mouses appication Pon I horn Si. Panel Mow)
The undersigned apneas that the work wit be done in accordance wish Caftans nibs and regulations and subject Io inspection and approval
211. BUSINESS PHONE
350-7610
❑ MAINTENANCE OF EXISTING
LANDSCAPING
• REGULATORY WARN .
INFORMATION 31014
❑ MOOFCATION OF TRAFFIC
CONTROL SYSTEMS
25. ORGANIZATION OR APPLICANT NAME (Print a Type)
City of Fontana, Engineering Division
❑ MOVE. TV RUING
27. ARCHITECT. ENGINEER OR PROJECT MANAGER NAME (R*V a Type)
Clyde E. Sweet, Jr.
2L BUSINESS PHONE
350-6600
2S. BUSINESS ADDRESS (Induct* Gay end 210 Code)
833533 Sierra aVenue Fontana, CA 92335
30.
AUTHORIZED
�SGLL
FM •t
31. PRINT OR TYPE NAUrE
Clyde E. Sweet, Jr.
32.TITL E 143.13ATE
Deputy City Engine r 04-30-93
W3
STANDARD ENCROACHMENT PERMIT APPLICATION
TFi 0100 (REV.31E2)
Pig. 2
Back
FEE CALCULATIONS BY CALTRANS
1. CALCULATED BY
CALCULATED BY 3. CALCULATED BY
p CASH
❑ SET FEE
p CHARGE
AS (Estlmassd)
❑ AX (Actual Cost)
p W JOR PROJECT EA
CURRENT HOURLY RATE S
FEE i DEPOSIT
1 FEE / DEPOSIT
2 ADDL. I DEPOSIT
3 TOTAL FEE
a. Bridge Tor (If APPsosbs)
S
S
S
b. Review I ) Set Fee
( ) Caktilned Fee
Estimated Hrs OS *
$
S
S
S
S
:
Additional Review & *
P.E.E.R. hours Hrs O S
S
$
EA
,
c. Inspection ( ) Set Fee
Calculated Fee
S
$
S
S
I )
Estimated Hrs OS *
S
S
S
EA
d. Field Work
( I Calculated Fee
S
S
TOTAL FEE / DEPOSIT
$
S
S
COLLECTED BY
COLLECTED BY
COLLECTED BY
INITIAL DEPOSIT PAID
$
ADDL. DEPOSIT PAID
$
TOTAL FEE
$
SURETY BOND REQUIRED?
p YES
NO
AMOUNT
$
UABIUTY INSURANCE REQUIRED? p YES
NO
AMOUNT
S
* The current hourly rate is set annually by
Headquarters Accounting, and takes
effect January 1. District Office staff do
not have authority to modify this rate.