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10004See below for Finance Revenue Codes Tit�t 4 aCP Qum& ENCROACHMENT PERMIT PUBLIC WORKS. CONSTRUCTION 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 Minor Improvement Permit - Class IV DATE: 1/21/2010 LOCATION OF CONSTRUCTION: Avenida Bermudas PURPOSE OF CONSTRUCTION: Street Closure for the 16th Annual SoaD Box DESCRIPTION OF CONSTRUCTION: Close Street and Temporary Construction of Ramps Used To Run Race DIMENSION OF INSTALLATION OR REMOVAL: N/A APPROXIMATE TIME WHEN WORK WILL BEGIN: 3/27/2010 ESTIMATED CONSTRUCTION COST: N/A permanent resurfacing and/or replacing improvements) COMMENTS TIME OF COMPLETION: 3/27/2010 (Including removal of all obstruction, materials, and debris, backfilling, compaction and placing 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 occuring 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 at (760) 777- 7097. To submit an inspection request, leave a message on the Inspection Request Hotline at (760) 777-7097 prior to 1:30 P.M. at least twenty-four (24) hours prior to the anticipated inspection. ---------- Comply with all applicable City Ordinances, the terms and conditions of the permit a all appl'a e (ules and regulations of the City of La Quinta and to pay for any additional replacement necessary as the result of t ' work. Sig at of Applicant or Agent IN Tatiana Hinkle - Desert Recreation District 45305 Oasis Street, Indio, CA 92201 760-393-5111/347-3484 Name of Applicant Business Address Telephone No Desert Recreation District 45305 Oasis Street, Indio, CA 92201 N/A Name of Contractor and Job Foreman Business Address Telephone No. N/A N/A Contractor's License Number City Business License No Philadelphia Indemnity Ins. Co PHPK403286 Applicant's Insurance Company Policy Number FEES Subdivision Improvement Permit - Class I Public Improvements: 3% of estimated construction costs Minor Improvement Permit - Class I Private Improvements: 3% of estimated construction costs Finance Revenue Code Inspection Fee EE=1 $0.00 Permit Fee E_1 $0.00 As -Built Deposit E-A $0.00 Cash Deposit -Surety Bond, E_B $0.00 if required TOTAL $0.00 PERMIT NUMBER: 10004 DATE ISSUED: / A - `Gtr h ;2� 2-0/0 EXPIRATION DE: o l / BY: - 0 WORK •INSPEC BY*: PERMIT COMPLETION DATE*: * If the work is covered by a Subdivision Improvement Agreement, Subdivider shall request final acceptance of improvements from the City Council. Todf °F4a PUBLIC WORKS DEPARTMENT APPLICATION FOR PERMIT Date: I %T um oll, 01.01 O 1 Tract No: _ Project Name: _ __ gOx _ _ Vicinity:, Gl f Mt4d&& (l4 [-a Chi ,U IiAba Purpose of Construction (i.e.: Rough Grading, Offsite Street, etc.) CoSt� C�.d<alie.�f���� Approximate Construction Start Date: 3 02� 10 Approximate Construction Completion Date: I - —0 TO Estimated Construction Cost: $FN Estimated Construction Cost shall include the removal of all obstructions, materials, and debris, back -filling, compaction and placing permanent resurfacing and or replacing improvements Contact Name: tjl_Cj i.aja _TJ _in lr Phone Number Name of Applicant/Owner: T� j Applicant Address:3�cj_�q,SIS (_ Applicant Telephone Number:– 5A}8i+ _ Applicant E-mail Address: 'o� ­d�trel.C'�ot,tb_ i51'i Name of Contractor: I,V ,%d2 —R�(r Contractor Address: (t}57�p5 ('�kSl� t,C�°1 •�22n1 Contractor Telephone Number: Contractor State License Number: Contractor City Business License Number: Contractor E-mail Address:1 I ►A COPY OF THE CURRENT INSURANCE CERTIFICATE MUST BE PROVIDED -4 Office Use Only: Inspection Fee: Permit Fee: l As -Built Deposit: Dust Control Deposit: Credit Amount: TOTAL FEE DUE: 10 Office Use Only: Assigned Permit Number: (ooO Approval Date: Expiration Date:_ Issue Date: Administrative Authority: Seivices *i&QAd + ' 1 ♦ ` t. ZIS s j TRAFFIC 'CONTROL PIAN SOAP BOX DERBY'/ MTOE I (RT)" EISENHOWER DRIVE C5 -DETOUR (RT F MARTINEZ MARTINEZ ZE MENDOZA ........ . ,- ..:. Drawn W. RN Do U 2! Cl 'DETOUR AHEAfi L A MAX& W -44,071,9M A0. Q VILLA\ALLA 77) CIO 'ROAD CLOSED AHEAD` Cl *DETOUR AHEAU" is C ts Of. P Era At- zqat4-r" NAVARRO.. NAVARRO- R2 '15 MPW- R42 'LEFT TURN ONLY r BERMUDAS ............. AVENllbA S 40' CONE SPACING 50.0' Toper -15 Cones, Zp�,,M,,T V30 rAzy'lvas 50' CONE' SPACING :516MS IM'STALLM Hd Ploce 15' from Curb Face 1990, P'Lovac. -r"E EAST SIDE OF ppomum)KQ. C2 'ROAD CLOSED' & C5 -DETOUR (LT) No Parking Signs to ibe. poste&,0t 100' spacing on the West aide of Avenldo Berm ud6s. 14 A r.,\pwdopi\staft\vorlongP\ACAD\tmf-wn\tocpbox.dw.9 ...... LEGEND • .TYPE 2 RAFOUCADE CIO 'ROAD CLOSED TRAFFIC ODNE AHEACr e) R26 'NO PARKINU Cl 'DETOUR AHEAD" R7 'KEEP RIGHT" 40' CONE SPACING 500' Toper — 30 Cones C3A ROAD CLOSED- TO THRU TRAFFIC & CS -DETOUR (RT) - C I T Y0 F LA Q U IN T A TRAFFIC ONtOl_ PIAN. SOAP .BOX DEREFY./ NTOE720.0 EXHIBIT `A' Ll Calle Ensenada ' . DON B•ERRY��MEMORIAL 77- F .GREATER-COACHELLA VALLEY SOAP'BOX•DERBY --—J' L—J Calle No alcs > Calle Chihuahua t cy- o A e D ' x c _ LJ �' v O Q �. 1 W Calle Monterey W Calle Colima Calle Arroba AC:UKUCERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 02/02/2010 PRODUCER BRUNER GOODHUE COOKE CRANZ 1168 TALLMADGE RD. CUYAHOGA FALLS, OH 44221-5158 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED INTERNATIONAL SOAP BOX DERBY, INC. PO BOX 7225 AKRON, OH 44306-0225 INSURER A: PHILADELPHIA INDEMNITY INS CO 18058 INSURER B: THE HARTFORD GENERAL LIABILITY INSURER C: 5/18/2009 INSURER D: EACH OCCURRENCE $ 1000000 INSURER E: V r-MAbCJ THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR DD' NSRD PE F C POLICY NUMBER POLICY EFFECTIVE DATE MMIDD/YY POLICY EXPIRATION DATE MM/DD/YY LIMITS A X GENERAL LIABILITY PHPK403286 5/18/2009 5/18/2010 EACH OCCURRENCE $ 1000000 COMMERCIAL GENERAL LIABILITY ©OCCUR OAMA N -TED PREMISES Ea occurence $ MED EXP (Any one person) $ CLAIMS MADE PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO - JE T LOC PRODUCTS - COMP/OP AGG $ 3,000,000 AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ (Ea accident) ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY $ . (Per person) HIRED AUTOS NON -OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ • ANY AUTO ' OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY' X OCCUR EICLAIMS MADE PHUB267676 5/18/2009 5/18/2010 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 DEDUCTIBLE X RETENTION $ 10,000 $ $ WORKERS COMPENSATION AND WC STATU-OTH- EMPLOYERS' LIABILITY TS I ER E.L. EACH ACCIDENT $ ANY PROPRIETOR/PAFTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - E EMPLOYEE $ If yes, describe under E.L. DISEASE -POLICY LIMIT $ SPECIAL PROVISION. below B OTHER SPECIAL RISK ACCIDENTAL 45SR750381 45SR705382 12/01/2009 12/01/2009 12/01/2010 12/01/2010 $250 Dental Limit, $5,000 Accidental Death $15,000 Excess Accidental Medical DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Certificate Holder(s) named below shall be an additional insured as pertains to the licensee, sponsorship or running of your All American Soap Box Derby Event to be run on the following date(s): TRIAL RUNS) - MARCH 27, 2010 RACE DATE(S) - MARC.H 27, 2010 RAIN DATE(S) - /^Cf']TICIl�ATr 1 VCr%1 Ir-I%.AI C rll'JLIJrM CANCELLATION Soap Box Derby of the Desert, Desert Recreation District, City of La Quinta, City of Palm Desert, Coachella Valley Community Recreation Foundation & all sponsors & volunteers 45305 Oasis St., Indio, CA 92201 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILJTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. , 1 ACORD 25 (2001/08) © ACORD CORPORATION 1988 GENERAL CONDITIONS --PERMIT NO. 10004 --GREATER COACHELLA VALLEY SOAP BOX DERBY -- This permit authorizes. special event activities to be accomplished within City of La Quinta right-of-way ONLY. Whenever the special event activities extend into private property, it is the responsibility of the applicant, or their agents, to secure permission from abutting property owners. Such authorization must be secured by the applicant prior to starting the special event activities. 1. The applicant, Tatiana Hinkle — Desert Recreation District, shall be available during the event by cellular phone at (760) 701-1005 or a message can be left at (760) 347-3484 ext 105 or (760) 393-5111. 2. The necessary traffic control signage, barricades, and cones identified on the approved traffic control plans will be provided and set up by the City. The applicant shall notify the City immediately if replacement equipment is needed. The applicant shall be responsible to have volunteers at the intersection of Bermudas & Nogales at all times during the event to allow residents living on Avenida Bermudas within the event area, their guests, mail carriers, and companies delivering to them, access to the southbound one-way fire lane provided on the traffic control plans. 4. The applicant shall also assign volunteers to regularly monitor the intersections of. 1) Bermudas & Chihuahua, 2) Bermudas & Monterey, 3) Bermudas & Colima, and 4) Bermudas & Arroba. 5. The permittee is responsible for making sure that temporary no parking signs along the parking area affected by the special event is existing. The signs shall be placed along the area 48 hours prior to the start of closing the area and.removed immediately after the construction completion date. 6. The City of La Quinta reserves the right to revoke, suspend or void this permit at any time. 7. The permittee shall indemnify, hold harmless and assume the defense of the City from all damages, delay costs, costs or expenses in law or equity that may arise out of work under this permit. T:\PERMITS\ENCROACHMENT\Numbers 10000\10004 -16th Annual Soap Box Derby; Avenida Bermudas; Close Street and Temporary Construction of Ramps Used to Run Race\SoapBoxDerby_condition.doc �����• u3/Z5/Zulu 10:zu ifly4 r.uuziuuz POLICY NUMBER: PHPK403286 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE name of additional Insured Persons Or Regional & local directors, local licensed organizations,sponsors of local & national races or rallies and lessors inrormauon required to comWete this Schedule, if not Section 11 — Who Is An Insured is amended to in- clude as an additional insured the person(s) or or- ganizations) shown in the Schedule, but only with respect to liability for "bodily injury', "property dam- age" or "personal and advertising injury' caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: A. In the performanceof your ongoing operations; or B. In connection with your premises owned by or rented .to you. will be shown in the CG 20 26.07 04 © ISO Properties, Inc., 2004 Page 1 of 1 0