0223NOTE: '
With;.4oper va1idati6n
.his fiorm constitutes an
encroachment permit
CITY OF LA QUINTA
APPLICATION FOR' PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
C -M
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
DATE: September 23, 1986.Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION Avenida Ultimo
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION install gas main. Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION to install 322 of 9V PA
medium pressure plastic gas ma , 12 N SPL of Avenida Ultimo
b&ainning 12' W.EPL of Washington St. proceeding east (See Sketch)
DIMENSION OF INSTALLATION OR REMOVAL
CUT -EAFaH AND MAC
SIZE OF EXCAVATION, IF. NEEDED
If other. than gas Co. forces preform
APPROXIMATE TIME WHEN WORK WILL BEGIN 9-25-86 the work, .a sWarte permit must be
obtained prior to start of any work.
APPROXIMATE TIME OF COMPLETION 12-25-86
ESTIMATED CONSTRUCTION COST $
(Including removal of all obstruction, materials, and debris,. backfilling, com tj��� l)
paction and placing permanent resurfacing and/or. replacing improvements)1, U l
In consideration of the granting of this permit, the. applicant hereby agrees to:
Indemnify, -defend and save the City, its authorized agents, officers, representatives and employees, harmless from and against any and all
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 (24) 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 of
La Quinta and to pay for any additional replacement necessary as the, result of this ,work.
J.M.' Snyder,- Distribution. StTervisor
Signature of Applicant or.Agent
Southern Calffornia Gas Ccnpany P.O. Box 2200 Riverside,•CA 92516 ..369-4512
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address ,Telephone No.
Contractor's License No. = - City Business License No.
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit —Class III
Public_ improvements:. 3% of estimated construction costs 6 �9W
Private improvements: 3% of estimated construction costs �NTERE�.+ SEP 2
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $ N/A
Receipt No.,
Received by 'Date
Recorded by
PERMIT VALIDATION
PERMIT NO. 223
.DATEAPPROVED 9-22-$6
EXPIRATION DATE 1-1-87
DATE ISSUED 9-23-86
BY , x.
Administrative Authority
TELEPHONE: (619) 564-2246-5f=v-