Courtesy Ground transportation Application packet - John Wayne ...

Ground Transportation Services
Courtesy Permit Packet

CheCklist form
Courtesy
Permit Paperwork (required):
Check-off as you prepare your permit package for submittal.
Application:
• Fill out top portion only, make sure all spaces are filled in or circled where indicated.
Security Deposit:
• Determine how many trips you plan on making each month/year and calculate on the provided form.
• Fill out a check for the amount of deposit, payable to John Wayne Airport.
Vehicle Registration & Picture: “See Sample”
• Provide a copy of the DMV registration for all vehicles.
• Please note on the registration the color, type of vehicle, # of passengers, and
If using a transponder from LAX or Ontario then write the transponder # on the registration.
• Provide one picture for each type of vehicle your company will be using here at JWA (shuttle, limo, etc).
Operating Permit:
• Fill-in the following spaces:
Page 1 – Company name only, (skip ‘Term of Permit’ portion)
Page 13 – Sign, title, and date
Insurance Paperwork (required):
Check-off as you prepare your permit package for submittal.
Certificate of Insurance
• Policy Limits:
Commercial Auto Policy
7 passengers or less $750,000
8-15 passengers $1,500,000
16+ passengers $5,000,000
• Workers Compensation/ Statutory
Employers Liability $1,000,000
Additional Insured Endorsement
• Separate page Auto Policy Endorsement
naming:
County of Orange/John Wayne Airport
Workers Compensation Waiver
• If no employees, submit Workers Comp
Waiver Form
• Description of Operations:
All Operations at John Wayne Airport
• Certificate Holder:
County of Orange/John Wayne Airport
3160 Airway Ave
Costa Mesa, CA 92626
Questions
Permit
Insurance
(949) 252 -5116 (949) 252-6037
Hand deliver or Mail all paperwork to:
John Wayne Airport Landside Office
18601 Airport Way, Box 41, Ste 116,
Santa Ana, CA 92707
Attention: Kathy Davis

COURTESY APPLICATION
GROUND TRANSPORTATION PERMIT
SNA JOHN WAYNE AIRPORT PERMIT PROGRAM
1. Type of Operator: (circle all that apply)
COURTESY
2. Type of Vehicle: (circle all that apply)
BUS SEDAN VAN LIMOUSINE SUV
Total number of vehicles to be operated at JW A
______
3. Passenger Capacity: (circle all that apply)
7 PASSENGERS OR LESS 8-15 PASSENGERS 16 PASSENGERS OR MORE
4. Company:
5. Primary dba:
6. Other dba(s):
7. Contact Name: 8. Title:
9. Email:
10. Address: 11. Suite No. or PO Box No.
12. City, State Zip
13. Work Phone: 14. Fax: 15. Cell:
John Wayne Airport Use Only
___ Signed License/Permit
___ CPUC-TCP Certificate, exp. ___/___/___
___ Security Deposit Calculation Sheet
___ Security Deposit / Amount $___________
___ DMV Registration for each vehicle
___ Transponder # from LAX or ONT (if applicable)
___ Picture of each type of vehicle being used at JWA
___ Application Packet Reviewed ____/____/____
___ Insurance / Approval Date ____/____/____
___ Permit signed by Airport Director
___ Entered into AVI: Acct No. __________
___ Service Start Date: ____/____/____
Revised 3/31/14 - ky

JOHN WAYNE AIRPORT
GROUND TRANSPORTATION
SECURITY DEPOSIT/FAITHFUL PERFORMANCE BOND
REQUIREMENT
All applicants must submit a security deposit. Use the calculation formula below to
decide what your required security deposit will be. The minimum deposit is $33.75 to a
maximum that is determined after completing the calculation formula below.
Calculation Formula
Estimated number of monthly trips __________ x $2.25 a Trip
= $_________ Monthly Fee, x 3 Months = $__________ Security Deposit
Examples:
Estimated number of monthly trips 5 x $2.25 a Trip
= $ 11.25 Monthly Fee, x 3 Months = 33.75 Security Deposit
Estimated number of monthly trips 26 x $2.25 a Trip
= $ 58.50 Monthly Fee, x 3 Months = 175.50 Security Deposit
Estimated number of monthly trips 72 x $2.25 a Trip
= $ 162.00 Monthly Fee, x 3 Months = 486.00 Security Deposit
JWA reserves the right to increase the
security deposit submitted by the applicant upon reviewing
the actual monthly trips made by the applicant.
c:\users\lsantos\appdata\local\microsoft\windows\temporary internet files\content.outlook\c64uhwfc\security deposit - calculation sheet.docRevised: 10/03/06 – ky

County of Orange
Request for Waiver of Workers’ Compensation Insurance Requirement
(To be completed by business, submitted to Purchasing or appropriate County Department. Department
attaches to Risk Assessment or Modification of Insurance Terms form and submits to CEO/RISK
Management )
Business Information:
Legal Name:
Address:
Legal Form:
Sole Proprietorship
Limited Partnership
Contact Name:
General Partnership
Corporation
Other:
Telephone:
Email:
County Information:
Department: John Wayne Airport Contract/Purchase Number: Customer ID #
Contact Name: Erika Cortina Telephone: 949-252-6037 Fax: 949-252-6053
Nature of Work: Ground Transportation On County Property YES NO
DECLARATIONS:
With respect to the above named business, I hereby declare and warrant that the business has no employees
other than the owners, officers, directors, or partners who have elected to be exempt from Workers’
Compensation coverage. I further warrant that I understand the requirements of Section 3700 et seq. of the
named business. I agree to comply with the code requirements and all other applicable laws and regulations
regarding Workers’ Compensation, payroll taxes, FICA and tax withholding and similar employment
requirements. I further agree to hold the County of Orange harmless from loss or liability that may arise from
the failure of the above-named business to comply with any such laws or regulations. I, therefore, request that
the County of Orange waive its requirement for evidence of Workers’ Compensation Insurance regarding the
above referenced work.
Name (print):
Signed:
Date:

I REGISTRATION CARD VALID FROM : 05/31/2006 TO :
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LINC 2005 2005 JZ 2006 32X
BODY TYPE MODEL NP MO AX we
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TYPE VEHICLE USE
COMMERCIAL
REGISTERED OWNER
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