Department of Beaches & Harbors

Applicant Information

Applicant Company **	Doing Business As *
Applicant Contact **	Applicant Title Mr. Ms. Mrs. Miss
Applicant Address **	Applicant City **
Applicant State * AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY	Applicant Zip Code **
Applicant Office Phone ** XXX-XXX-XXXX	Applicant Cellphone ** XXX-XXX-XXXX
Applicant Email ***	Re-Type Email ***

Permit Scope and Purpose

Work Description **

​​​Requested Dates and Locations
(Construction work hours are restricted to 8:00 AM to 5:00 PM, Monday through Friday, no weekends or holidays)

Start Date and Time **	End Date and Time **
Work Location Description **

Staging Area	Staging Area Description *
Workers Parking	Number of Parking Spaces Needed **
Temporary Ingress/Egress

Permit Details
   Equipment to be used:

Trucks	Backhoe
Dumpster	Trailer
Monitoring Device
Additional Equipment *

Haul Route required *(If Yes, a Caltrans permit might be needed.)	Haul Route Description *
Toxic Chemicals used	Toxic Chemicals Description *
Beach Driving

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WARNING: COMPLETION OF AN APPLICATION CONFERS NO PRIVILEGES UPON THE APPLICANT. DO NOT ATTEMPT TO ENTER OR USE THE PROPERTY UNTIL YOU HAVE RECEIVED A FULLY EXECUTED PERMIT. ANY ATTEMPT TO ENTER OR USE THE PREMISES MAY CAUSE YOUR APPLICATION TO BE REJECTED AND MAY SUBJECT YOU TO CIVIL OR CRIMINAL PROSECUTION.