Form Center

2. Public Works Project Number*
3. Date*
   Date
4. Permit Number*
6. Type of Encroachment*

   1. Bench
   2. Roll-Off Bin
   3. Trash Can

   1. News Rack
   2. Scaffolding

   1. Sign in Right-of-Way
   2. Planter Box

   1. Table/Seating
   2. Other
8. If other, please specify:
10. Property Owner*
11. Phone Number*
13. Street Address*
15. City*
16. State*
17. Zip Code*
19. Email Address*
23. Work Address*
25. City*
26. State*
27. Zip Code*
31. Contractor Name*
32. Phone Number*
34. Email*
36. Street Address*
38. City*
39. State*
40. Zip Code*
42. Contractor License*
43. Alternate Phone Number*
45. Description of Encroachment*
47. Public Work Requirements*
49. Permit Amount*
50. Description*
51. Receipt Number*
53. You are responsible and liable for personal injury and/or property damage caused by this work or your failure to do what you are obligated to do. If claim of such liability is made against the City or any of its departments, officers, or employees, you shall, and hereby agree to, defend and indemnify the City and hold the City harmless from any claims, including cost of defense and attorney fees.
55. All work shall be completed and the right-of-way restored by:*
    All work shall be completed and the right-of-way restored by:
57. Agreement
    I have read this permit and acknowledge receipt of the City of Solvang Encroachment Permit General Provisions and the attached special conditions which I have read, agree to, and acknowledge as part of this permit.
59. Signature*
60. Date*
    Date
64. Office Use Only
66. Department of Public Works
69. Required Reviews
Leave This Blank:


72. Print Only

* indicates a required field