County of Santa Barbara

ROAD ENCROACHMENT PERMIT APPLICATION

FEE SCHEDULE Permit No.: ________________

Application Date:	[None]
ASSESSOR PARCEL NUMBER:
ENCROACHMENT ADDRESS:
DESCRIPTION OF WORK:

APPLICANT INFORMATION

Check one: Owner Authorized Agent
Name:		E-Mail:
Mailing Address:
Telephone:	CelPhone:	Fax:

CONTRACTOR INFORMATION

Company Name:		Representative:
Telephone:	CelPhone:	E-Mail:
Address:		State Lic.:
Worker’s Comp. Insurer:		Exp. Date:

ARCHITECT/ENGINEER

Company Name:
Company Rep.:		Registration No.:
Telephone:	CelPhone:	E-Mail:
Address:

AUTHORIZATION SIGNATURE BLOCK

I/We authorize and give consent to to act as my/our authorized agent to apply for, sign, and receive in my/our behalf; a Road Division Encroachment/Excavation Permit. I/we understand that as the legal property owner where that encroachment/excavation is to take place, that I/we are responsible and liable for all actions, costs, and liabilities associated with this Encroachment/Excavation Permit.

Signed: Date:

OWNER/AGENT SIGNATURE BLOCK

I hereby make application to excavate and/or encroach in the Public Road/Right-of-Way at the location(s) and as described herein, subject to the provisions required to Ordinance No. 1491, of Santa Barbara County, applicable State or Federal Regulations, AND ANY SPECIFIED REQUIREMENTS ATTACHED HERETO. It is agreed by the applicant that the County of Santa Barbara and any officer or employee thereof shall be save harmless by the applicant from any liability or responsibility for any accident, loss or damage to persons or property, happening or occurring as the proximate result of any of the work undertaken under the terms of this application and the permit or permits which may be granted in the response thereto, and that all of said liabilities are hereby assumed by the applicant.

Signed: Date:

Address: Phone: