12065 (2)See below for Finance Revenue Codes
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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.
�® MW� Subdivision Improvement Permit - Class III
Minor Improvement Permit - Class IV
DATE: 9/25/2012
LOCATION OF CONSTRUCTION: Madison Street from Avenue 50 to Avenue 52
PURPOSE OF CONSTRUCTION: City of Indio Madison Street Improvements; Determine Depth from Finished Surface to Top of Buried Uti
DESCRIPTION OF CONSTRUCTION: Perform Vacuum Excavation
DIMENSION OF INSTALLATION OR REMOVAL: See Attached Exhibits.
APPROXIMATE TIME WHEN WORK WILL BEGIN: 9/24/2012 TIME OF COMPLETION: 9/26/2012
ESTIMATED CONSTRUCTION COST: $7,000 (Including removal of all obstruction, materials, and debris, backfilling, compaction and placing
permanent resurfacing and/or replacing improvements)
COMMENTS All Work and Equipment Will.be Off the Street
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 and all applicable rules and regulatio of the ity
of La Quinta and to pay for any additional replacement necessary as the result of this work.
Signature of Applicant or Agent
Shea - Michael Anti, PE
Name of Applicant
C Below, Inc.
Name of Contractor and Job Foreman
959964
Contractor's License Number
Hartford Casualty Ins. Co.
Applicant's Insurance Company
FEES Subdivision Improvement Permit - Class I
Minor Improvement Permit - Class I
14280 Euclid Ave, Chino, CA 91710 888-902-3569 x211
Business Address Telephone No
14280 Euclid Ave, Chino, CA 91710 888-902-3569 X211
Business Address Telephone No.
99549
Finance Revenue Code
Inspection Fee E_1
$0.00
Permit Fee E_1
0.00
i As -Built Deposit E-A
0.00
Cash Deposit -Surety Bond, E_B
0.00
if required
TOTAL
$0.00
City Business License No*
72 SBA UV3557
Policy Number
Public Improvements: 3% of estimated construction costs
Private Improvements: 3% of estimated construction costs
PERMIT NUMBER: 12065
DATEISSUED:
EXPIRATUE. ft ATE:
BY:
WORK INSPECTED BY*: IO-tZ• 12-
PERMIT
ZPERMIT COMPLETION DATE*: b4N4 V&L5rvwe-L--C1,.
* If the work is covered by a Subdivision Improvement Agreement, Subdivider
shall request final acceptance of improvements from the City Council.
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