HomeMy WebLinkAbout1135 Drake Avenue - PW23-0114 - StandardCash Register Receipt
City of Burlingame
Receipt Number
B41941
DESCRIPTION ACCOUNT QTY PAID
PermitTRAK $468.00
PW23-0114 PW-SEWER TEST Address: 1135 DRAKE AVE APN: 026182050 $468.00
Owner: HAYDOCK WILLIAM K JR TR FETTY CYNTHIA TR Applicant: LINDSTROM COMPANY
Contractor: LINDSTROM COMPANY
Construction Cost: $0 Job Description: Sewer Test
ENCROACHMENT PERMITS $468.00
SEWER LATERAL TEST PW0301 101310 43301 91 0 $468.00
TOTAL FEES PAID BY RECEIPT: B41941 $468.00
Printed: Friday, March 24, 2023 9:14 AM
Date Paid: Friday, March 24, 2023
Paid By: LINDSTROM COMPANY
Pay Method: ONLINE CC 105519
1 of 1
Cashier: LC
3/24/23, 9:18 AM PW Reviews Application
https://burweblink.burlingame.org/Forms/form/submission/history/7893/17202?hideHeader=true 1/4
City of Burlingame Street and Public Rightof Way Encroachment Permit Application
Permit fees will be assessed according to the master fee schedule in effect at
the time the permit is issued.
Review Public Works Procedures
Initial*
Check All that Apply*(?)
Description of work:
Initial below after you have reviewed the Public Works Encroachment Permit Procedures, Conditions for
Issuance, and Standards for Insurance.
THL
What kind of work are you seeking to perform in the public right of way?
Parking
Sewer Test
Sewer Lateral Replacement
Remove and Replace Utilites for new residence or construction
Sidewalk/Curb & Gutter/Driveway
Curb Drain
Water Service
PG&E Permit
Telecommunications Utility Permit
Fire Service
Sidewalk Closure
Traffic Control
Other
Sewer Test
All construction work shall be done in accordance with the most current City of Burlingame Municipal Codes, City Standard Details and Specifications,
APWA-AGC Standard Specifications for Public Works Construction, and the California Stormwater Quality Association’s Stormwater Best
Management Practice Handbook.
3/24/23, 9:18 AM PW Reviews Application
https://burweblink.burlingame.org/Forms/form/submission/history/7893/17202?hideHeader=true 2/4
Start Date
End Date
Work Location Street Number *
Work Location Street Name *
Applicant's Name*
Is the work address the same as your home address?
Applicant's Address
Applicant's Email *
Applicant Phone Number*
Is a contractor is working on your project?
Timeline
3/22/2023
4/5/2023
Work Information
1135
Drake Avenue
Todd
Yes
No
City
San Mateo
State / Province / Region
CA
Postal / Zip Code
94401
Country
Street Address
1121 Bayswater Avenue
Address Line 2
todd@lindstromco.com
6502086217
Yes
No
3/24/23, 9:18 AM PW Reviews Application
https://burweblink.burlingame.org/Forms/form/submission/history/7893/17202?hideHeader=true 3/4
Is there sidewalk work on your project?
Provide drawing(s), traffic control plans or approved plans of proposed work including, but not limited to
location and dimensions of all affected area within the public right-of-way per the requirements outlined in
encroachment permit procedures and conditions for issuance.
Please upload proof of insurance.
Insurance
Who shall we refund the bond to if needed?
Signature
Date *
Yes
No
Uploads
Insurance Upload
Public Works staff may require additional documentation such as a certificate of insurance prior
to the issuance of an encroachment permit.
Click here for the standards of insurance.
Refunds and Signatures
In Submitting This Application, I/We Agree To Accept And Comply With All Procedures And Conditions Set Forth In This Permit Application, And Agree
That Said Procedures And Conditions Shall Be Binding On Permittee(S), Contractors And Subcontractors Performing The Work, Co- Owners, Heirs,
Assigns, Transferees And Successors Of Interest Of Every Nature. I/We Agree To Save, Keep, And Hold Harmless, Indemnify And Defend The City Of
Burlingame, Its Officers, Employees, Authorized Agents From Any And All Damages, Claims, Liabilities, Penalties, Cost, Or Expense In Law Or
Equality That May At Any Time Arise, Result From, Related To, Or Be Set Up Because Of Damages To Property Or Personal Injury Received By
Reason Of, In Whole Or In Part, The Negligence, Recklessness, Or Willful Misconduct Of My/Our Officers, Employees, Contractor, Subcontractor, Or
Agents. I/We Hereby Affirm Under Penalty Of Perjury That The Above Information Is True To The Best Of My Knowledge.
3/22/2023
3/24/23, 9:18 AM PW Reviews Application
https://burweblink.burlingame.org/Forms/form/submission/history/7893/17202?hideHeader=true 4/4
Date Permit Issued
APN Number
PW Permit Number
Bond Refunded
Date-finaled
3/24/2023
026182050
PW23-0114