12067 (2)•4.
Qumli
ENCROACHMENT PERMIT
PUBLIC WORKS CONSTRUCTION
See below for Finance Revenue Codes
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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: 1/1/2013
LOCATION OF CONSTRUCTION: South Side Avenue 52, 214' East of Jefferson Street
PURPOSE OF CONSTRUCTION: Crown Castle; LAD088-05; Street Light Pole w/ Assoc. Equip., 1 -Elect. Meter Pedestal, Conduit, &Fiber Splice Box
DESCRIPTION OF CONSTRUCTION: See Attached Plans
DIMENSION OF INSTALLATION OR REMOVAL: 30' Pole, 23' (1) 2" Conduit, (1) 24"x36" Fiber Splice Box
APPROXIMATE TIME WHEN WORK WILL BEGIN: 2/11/2013
TIME OF COMPLETION: 3/11/2013
ESTIMATED CONSTRUCTION COST: $15,000 (Including removal of all obstruction, materials, and debris, backfilling, compaction and placing
permanent resurfacing and/or replacing improvements)
COMMENTS
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 employ 44
harmless from and against any
and all penalties, liabilities or loss resulting from claims or court action and arising out of a�ya6cident, loss or damage to persons or
property happening or occuring as a proximate result of any work undertaken under th ermit 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 Reque§tHothne:af(760) 777 7U97;pnor�to 1 30 P Meat•
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 regulations of the City
of La Quinta and to pay for any additional replacement necessary as the result of this work.
�Si J t or Agent
Crown Castle - Steve Patino
Name of Applicant
PWC - Scott Ivey
Name of Contractor and Job Foreman
597074
Contractor's License Number
Old Republic General Insurance Co
Applicant's Insurance Company
FEES Subdivision Improvement Permit - Class I
Minor Improvement Permit - Class I
Finance Revenue Code
Inspection Fee EE=1
Permit Fee E-1
As -Built Deposit E-A
Cash Deposit -Surety Bond, E_B
if required
TOTAL
y�8�i3
1100 Dexter Ave #250, Seattle, WA 98109
Business Address
900 Gladstone, San Dimas, CA 91773
Business Address
450.00
$100.00'
0.00
0.00
550.00
805-234-1431
Telephone No
909-592-4321
Telephone No.
106739
City Business License No
A -I CG -968512-02
Policy Number
QUINTA
DEPT. Pu lic Improvements: 3% of estimated construction costs
Private Improvements: 3% of estimated construction costs
PERMIT NUMBER: 12067
DATE ISSUED: Z ZS 13
EXPIRATION D E:
BY:
WORK INSPECTED 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.
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