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2. 
3. Annual Encroachment Permit Holder Project Notification Form & Emergency Work Notification Form

   Holders of an Annual Encroachment Permit (AKA "Special Permit") shall notify the Department when performing work in the County right of way under the annual permit. [Reference: County Code 411-11(k) and (l)]. Anyone performing emergency work within the County right of way shall notify the Department of Public Works. [Reference: County Code Section 411-11(a)] Submital of this form electronically on the County website shall be used to notify the Department of Public Works - Land Use Division of work done under the annual permit or to report work done in an emergency. Reporting is to be done prior to working in the right of way; however it is understood that due to unforeseen circumstances there may be an occasional need to report work after the work has been completed. Please report all work in a timely manner.

5. *** THIS IS NOT A PERMIT ***
7. 1. Name of Annual Permit Holder:*
9. 2. Contact Person:*
10. Contact Person Telephone No.:*
11. Contact Person Email:
13. 3. Is this Emergency Work?*

    1. Yes
    2. No

    Select the type of work being done
15. 3A. Party performing the work*

    1. Own Forces
    2. Contractor
17. 3B. Name of Contractor*
18. Contractor Telephone No.*
20. 4. County Road Name*
24. Project Location (Google Maps Coordinates):
    Using Google Maps, insert a Placemark at the location where the project work will be done. Copy and paste the coordinates into the cell below. (Example: 40.780407, -124.161374) For help use the link below for the Google Maps Help File.
26. 5. Project Latitude and Longitude*
    Paste the latitude and longitude from Google Maps. Example: 40.780407, -124.161374
28. Google Maps Help File
    https://ca-humboldtcounty.civicplus.com/DocumentCenter/View/58893
32. 6. Type of Work:*

    1. Emergency Repair / Emergency Maintenance
    2. New Service Lateral / Hookup
    3. Maintenance Work - Main Line
    4. Maintenance Work - Service Lateral / Hookup
34. 7. Brief Project Description*
    Enter a brief description of the work being done: pole replacement; new pole; trenching; guy wire replacement; new guy wire; new overhead service; new underground service; etc... (120 characters)
36. 8. Work Location:*

    Check ALL boxes that apply:

    1. Sidewalk Area
    2. Paved Road Surface (travel lanes)
    3. Paved Road Surface (parking lanes and/or shoulders)
    4. Unpaved Road Surface (travel lanes)
    5. Undeveloped Road Area / Shoulder Area
38. 9. Will the work require the road surface or sidewalk to be restored/repaired?*

    1. YES
    2. NO
40. 10. Will the work result in the placement of facilities in, on, or above the sidewalk area?*

    1. YES
    2. NO
42. 11. Estimated starting and ending dates for the work*
    11. Estimated starting and ending dates for the work Start Date

    —

    11. Estimated starting and ending dates for the work End Date
    Note: You do not need to submit a new form if the actual work dates vary from the estimated dates.
44. Contact Information

    Encroachment Permit Office | Land Use Division | Humboldt County Department of Public Works | 3015 "H" Street | Eureka | CA | 95501 | TEL: 707.445.7205 | FAX: 707.445.7388 | EMAIL: PublicWorksPermits@co.humboldt.ca.us

Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit Submit and Print

* indicates a required field