Unified Application for Encroachment Permit

Unified Application for Encroachment Permit

County of Marin Department of Public Works -- Land Development Division
Application Date and Location
Application Date:*

MonthDayYear
PM/WO/JB# (if applicable):
APN Number:
Location of Work or Encroachment:*

Street Address

Street Address Line 2

City/TownshipState / Province

Zip Code
Cross Street:
Estimated Cost:
Starting Date:*

MonthDayYear
Completion Date:*

MonthDayYear
Property Owner's Name if Different From Applicant:
The Undersigned Hereby Applies for Permission to Perform the Following Described Work and/or Otherwise Encroach on a Local Agency Right-of-Way (ROW):
Description of Encroachment (Include Plans or Sketch)
Check All That Apply to the Project:*

Driveway ApproachCurb & GutterSewer ImprovementSidewalkWater ServiceExcavationAccessible RampNew UtilitiesLandscapingSpecial EventDebris Box/PODOther (Describe)
Provide a Written Description:*
Attachments:*

Please attach a site map, drawing, or sketch.
Cancelof
Road Closure?

NoYes
If Yes, How Many Days?
Road Surface Type:

AsphaltConcreteOther
Any Trenching or Excavation Work in a Street?

NoYes
Linear Feet (street):
Example: 4'11"
Surface Thickness (street):
Example: 1'4"
Any Trenching or Excavation Work on a Sidewalk?

NoYes
Linear Feet (sidewalk):
Example: 4'11"
Surface Thickness (sidewalk):
Example: 1'4"
Traffic Control Plan:

NoYes
Traffic Control Plan Attachment:

Cancelof
Work associated with a Building Permit*

YesNo
Provide building permit number or tracking number
Applicant agrees that all work will be performed in accordance with the rules, regulations and standards of the Local Agency Department of Public Works and any Local Municipal Code. All work shall be subject to inspection and approval by the Department of Public Works. Applicant shall indemnify, defend and hold the Local Agency, its officers, agents and employees harmless from any and all claims, suits or liability, including, but not limited to, litigation costs and attorney's fees which the Local Agency may incur as the result of any and all claims and suits for personal injury, property damage or inverse condemnation by reason of applicants placement of/or maintenance of encroachments authorized by this permit. No work shall commence until permit is issued.
Applicant/Permittee Information
Applicant's Name/Company:*
Attach Certificate of Liability Insurance or Homeowner's Insurance Policy:*

Cancelof
Is Applicant a Utility Governed by CPUC?

YesNo
Contractor's License Number:*
Applicant's Mailing Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Daytime Phone:*
Please enter a valid phone number.
Email:*
example@example.com
Acknowledgement: the information on this form is true and accurate, and I represent the applicant/permittee. My electronic signature agreeing to the afore-mentioned is below.*

I agree
Applicant's Signature:*
After clicking submit, the applicant will receive confirmation of their submission at the email address provided above.
For DPW Use Only
Approved:

YesNo
Comment/Reason:
Plain text only; no HTML
County Maintained Road?

YesNo
Is the Contractor's License Valid?

YesNoN/A
Fees
Application:
Number in dollars
Plan Review and Inspection:
Number in dollars
Total:
General Comments:
Plain text only; no HTML
DPW Land Development Signature:
Date Signed:*

MonthDayYear
Org Code:
Final Approval:
Done:

NoYes
Revised Feb. 2022
Should be Empty:

Unified Application for Encroachment Permit

Application Date and Location

Description of Encroachment (Include Plans or Sketch)

Applicant/Permittee Information

For DPW Use Only

Fees