Chain Link Fence (771-140-021)N01 _
With.
proper validation
this form constitutes an
encroachment permit CITY OF LA QUINTA c...
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
D
For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
Subdivision Improvement Permit — Class III
r DATE 1 ' jj Minor Improvement Permit Cln-,,, P
LOCATION OF CONSTRUCTIOi. \1:R _ �7C'►r VQrz
(Street address or Description of Locauori
)
PURPOSE OF CONSTRUCTION � ����L"�— � � � � ►� � Sketch (attach construction plans if appropriate)
1 ter, C Y.P�'I� v1Ji.rG flJ�
I QESCRIPTION OF CONSTRUCTIOr':L)'5-3i-
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i 0_c�,e jI1'1 �] QC's { i Y O ► -_
DIMENSIO OF INSTAy LAT IONOJR 9VAL �5 ~� fl gC_ �'CK
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SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION G�_) - I L;7 _'"
ESTIMATED CONSTRUCTION COSTS — - �, Jo `a' 9<)
(Including removal of all obstruction, materials, and debris, backfilling, com-
paction and placing permanent resurfacing and/or replacing improvements)
In consideration of the granting of this permit, the applicant hereby agrees to
Indemnify, defend and save the City, its authorized aoents, officers, representatives and employees, harmless from and against any and 'fl:
penalties, liabilities or loss resulting from claims or court action and arising out of any accident, loss or damage to persons or property
happening or occurring as a proximate result of any work undertaken under the permit granted pursuant to this application
Notify the Administrative Authority at least twenty-four (241 hours in advance of the time when work will be started.
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules and regulations of the City 01
La Quinta and to pay for any additional replacement necessary as the result of this work -
Signature of AP iicant or Agent
At•rj >t 0. A C -IC 7Ypga moi.. ��� "��Z G�
Name of Applicant (please print) +� ^Business Addr l Telephone No.
J^f 14-�D it i1) 1-,3C Z) Y. L 7 r YPr S Q
Name of Contractor and Job Foremar, Business Addres_- Telephone Nc
Contractor's License No City Business License No -
Applicant's Insurance Compan,, Policv Numbe-
FEES: Subdivision Improvement Permit —Class 111
Public improvements: 3% of estimated construction costs
Private improvements: 3 of est:matea construction cos'-
rvimor improveriient Perm:,, — C;ac: 1%1: S_e attacnec scnec'.�•
Inspection Fee
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by
Recorded by
S
S
Date
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED -
EXPIRATION DATE
DATE ISSUED
By
TELEPHONE: (619) 564-2246
Administrative Authori
ATE
COMPENSATION P.O. BOX 807, SAN FRANCISCO, CALIFORNIA 94101
1 NSURAXP4CE
U�
9-7-83
CERTIFICATE OF WORKER'S COMPENSATION INSURANCE
POLICY NUMBER: 443098-83
CERTIFICATE EXPIRES:
4-z-84
Soo California Water Co.
P.O. Box 6
1a Quinta, CA 92253
This is to certify that we have issued a valid Worker's Compensation insurance policy in a form approved by theC.ali`cnt:.-:
Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon ten days' advance written notice to the employer.
We will also give you TEN days' advance notice should this policy be cancelled prior to its normal expiration.
i nis certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded 11y ih;
z;olicies listed herein. Notwithstanding any requirement, term, or condition of any contract or other documiei with.
respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the poiicios
described herein is subject to all the terms, exclusions and conditions of such policies.
Job: All Operations
EMPLOYER
Alcorn Fence Company
P.O. Box 1249
Sun Valley, CA 91352
SCIF FORM 262A (REV 12-80)
PRESIDENT
C-22-�33
MA 67 Ido Z
/D $