13021 (2)See below for Finance Revenue Codes
• M
OU 4 4a QU
ENCROACHMENT PERMIT
PUBLIC WORKS CONSTRUCTION Nov
,&
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
q=C:D) Minor Improvement Permit - Class IV
DATE: 2/12/2013
LOCATION OF CONSTRUCTION: Jefferson Street South of Avenue 52 (Next to Canal)
PURPOSE OF CONSTRUCTION: Reduce Drain Pipe Size Coming from Force Main Encasement
DESCRIPTION OF CONSTRUCTION:
DIMENSION OF INSTALLATION OR REMOVAL: Reducing from 6" to 2" Pipe
APPROXIMATE TIME WHEN WORK WILL BEGIN: 2/13/2013
TIME OF COMPLETION: 2/22/2013
ESTIMATED CONSTRUCTION COST: $5,000 (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 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 applica e s and re lations of the City
of La Quinta and to pay for any additional replacement necessary as the result of this work.
X # 77 !�_
Signatr of Applicant or Agent
CVWD - Juan Martinez
Name of Applicant
Own Forces
Name of Contractor and Job Foreman
N/A
Contractor's License Number
Self -Insured
Applicant's Insurance Company
FEES Subdivision Improvement Permit - Class I
Minor Improvement Permit - Class I
75-525 Hovley Lane East, Palm Desert, CA 92211
Business Address
Business Address
Finance Revenue Code
Inspection Fee EE=1
$0.00
Permit Fee E_7
$0.00
As -Built Deposit E-A
$0.00
Cash Deposit -Surety Bond, EE=6
$0.00
if required
TOTAL
$0.00
(760) 398-2651 x 3629/ 902-4392
Telephone No
Telephone No.
N/A
City Business License No
Self -Insured
Policy Number
Public Improvements: 3% of estimated construction costs
Private Improvements: 3% of estimated construction costs
PERMIT NUMBER: 13021
DATE ISSUED: ;? - I
EXPI"N DATE:
BY. [/ _
WORK INSPECTED BY*:
PERMIT COMPLETION DATE*: 2 -/LT•/3
If the work is covered by a Subdivision Improvement Agreement, Subdivider
shall request final acceptance of improvements from the City Council.