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With proper validation
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this form institute's an f+ 4CITY "OFA l±A' UINTA
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encroachment permit
` APPLICAT:I91 FORM PERMIT
.JRU LIC l' i.
WORKS C NS RUCTION E CRO CH ENT
For' the construction of "public : or private burbs, '`driveways, 'pavements, sidewalks,.;parking lots," sewers, water` mains
and other like public works improvements in+connection yvith MINg 3 IMP.RQVEMENTS and APPROVED SUBDIVISIONS
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. _ �' �, � 5 •1' . ;r Subdivision, Improvement emit Cass°111
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DATE:_ April 30 t x 287 � ?, :t'L1 Y,r,T' � � �j"J.�'c„' Minos Improvement Permit Class IV XX
LOCATION OF CONSTRUCTION,]}•Washington .Street fc= 50th Avenue. 'to, Fred Waring Drive i
j and in' Sagebrush and Date
(Street aq ass Qr Descr pIipn pf pkat ori)'' 1 {
' 'sr�, rF �'Sri.L � S'v' �-:+T-kF�4 a!J i.^' F?. r.ia-:. 3 JLr+a'� � .• Ri, S. ��.r,ra •M1e FF �'.y �M►��•r�'w x. of ." 1,1 f J 4µ.';a1-i,..� �. � 1 L�.. vl
PURPOSE OF.CONSTRUCTION' ;Sewer: line co nstructibn � . Sketchr(attach construction plans if a propriate)
DESCRIPTION OF CONSTRUCTION' ewer force. man S-ee project plans 34 sheets
and
appurtenance c"fr i`� 7•K Rrs t' -, Q le.�M,rJ%�R.ac.�
PP ,,pec3a:.� 's fit, 41«:t{ sx
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• ' pIMENS ON OF IN TALLATION OR REMOVAL18 renc Notes. -The attached General and
17, 40� "feet ong(port Qn.'o ;wor n77ooun' y > 0<„ Special ?rov ;A�gns are
*� ; ^ t tn, j;t ,r� ? incltadgd,,and made at girt
' SIZE OF EXCAVATION; IF,NEEOED° . fir" = ti. '''t' ,, tih l `I b.
une , A 'Separate encroachment permit
! APPROXIMATE TIME WHEN WO�tK'WILL BEC"IN 1
r . �:, .tt "' i,. ri r- t '� _ ,wilA. be' ,reggArqd .# suer force
anuary ,; main.work is performed by�other F
4` APPROXIMATE TIME OF.COMPLETION , y
ESTIMATED CONSTRUCTION CQ$T $ .f,� > ;t11 ;1 C.V.W;.T .3,. + C�9,.: + , •��
Y (Including removal- of all obttruction, materials, and debris, backfilling, com
paction and 1.-. USA,- Inquiry JJQ..•t' .3 ; �• i
placing, permanerit resurfacing andlor °replacing improvements)
Date ll - i
'Jn consideration of the granting'of th's pprmlt, the apphi thereby agrees ,to j
� ' "eby,, vitt
Indemnify, -defend aro 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 s
happening or occurring as a proximate result of any work undertaken udder the permit -granted pursuant to ,this application.- 7
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Notify the Admigqrstrative. Authoritl(, t least twenty-four (241. hours t advance of the ime wh n work will a started.
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Comply with al•II,applicable City, Qrdi onge the terms ar�d di i' of the,perm it .acrd, II- p icable rules ertdj regulations of the City of { i
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l.q 4uint� and req PeY for X MI radd io I r Placement necass r I'' MOUNt s+l� i hislw ri4 :�4t.puOji" 7 �fi�L'i.k, ? I
E�tj:0.-:CLQ 4 J'rt otd'. �' .�..' t"4�"��kd�t,� � �J ci `£.'{"1t`� �. f . elll . •i
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S gnajur of Applicant or Agent
COACHELLA VALLEY --WATER DISTRICT# .P. '0. BOX 1058, 'Coachella, CA 398-2651 ' ' +
Name of Applica qt (please,p�int)41ti .43:1 ^'" +"=r ±,1 .Business Address= 4I.rV,.?tCA� gtrt�is� Telephone No.° • i `
8' Mr. Citarlela ,iav®r & Aasociatels, Y374--390 , Hwy 111,. Palm. Desert', CA 346-7481.a
Name of Contractor nd . ok Foremtn,4 , �. e��Addre s'.L ��,x"z;i.C; lit 'K, t el�epho�n�e.No.
Bu
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Contractor' i nse No. f �* • "
_ ;! It;ce#� Y •�}�y ��y Ly { . _ t * City'�B1u�+siness License I�[o.'
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Applicant's Insurancew gmpanY� ,•r„-= On• i-,14
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" 'FEES:. Subdivision Improvement Permit — Class I II
,Public improvements: 346 of estimatedconstruction costs
'
Private ifrtproverrleptt t %of; st )nated cQrt yuctipp cq�ts:.
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' 4 Minor. Improvement Permit = Class IV: See attached schedule
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Inspection Fee $
PERMIT VALIDATION
Permit Fee
Tit
PERMIT NQ.
.� Penalty ,r•r '� �µ- 11 "'Jif s J E �f
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DATE APPROVED
eposit.... nt, . f� .,
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;�+ �:��.r+. � ,. •, ws'''�a .. ,
if required ctt,iqkw €`i
�:';` EXPIRATION DATE z. � 1: / `f Af °7
'2TOTAL: 1%W(,$ `'
��
^ N::t
�` DATE ISSUED"''
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Receipt -No.
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BY -
ReGeived�by *Pate, 0 .,o
, ., <` :.' t+i;. rM t r"1lrt�rt :„i.� .i :c . .Admini, __ative, . uthotity
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4 , tX ►!', C;. al 9 n~�'rsilntlu� ri r.Ut11J v-
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Recorded by
�, yTELEPHONE (6.19) §6 -?246, it'.
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'Gr ttllli:.il:st't.i.sR Utoyroof uN, ;�i•� . �.�z�• aj� 3�
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VC -1 +7 IOLrOYV LV IIL.011.70L%�.'�1l 011 IIIpOI"VYJ+,YI`Y'O L%I OLrLIIp'O/L I'Ia0 (/1.111 011lllllvv /•�. 111 how avcii5.1 rw1va alwmll t11n
ties to these monuments shall be furnished to'the City Engineer
prior to the removal of any monuments. This office shall
be notified upon completion of replacement all survey monuments for propt�elrfipaprojectclearance. �f
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u{of
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