2331PTOTE:
With proper validation
this form constitutes an
encroachment permit
CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
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 I I I
DATE: 3 23-95 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION Avenida Bermudas from Arroba to Nogales
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Bold Soap Box Derby
on Avenida Bermudas on 3-25-95
DESCRIPTION OF CONSTRUCTION Close Bermudas from Arroba
to Nogales to hold Soap Box Derby Race (1 day)
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN 3-25-95 6200 am
Sketch (attach construction plans if appropriate)
APPROXIMATE TIME OF COMPLETION 3-25-95 7100 pm
ESTIMATED CONSTRUCTION COST $
(Including removal of all obstruction, materials, and debris, backfilling, com-
paction and placing permanent resurfacing and/or replacing improvements)
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 occurring 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.
Comply with all applicable City Ordinances, the terms and conditions of the er it and all applicable ruiesInd regulations of the City of
La Quinta and to pay for any additional replacement necessary as the resu of this work.
Name of Contractor and Job Foreman
Business Address
Telephone No.
Contractor's License No. City Business License No.
Great American GLP 7--01-22-01-01
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Class 111
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $
Permit Fee
0
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $ —0
Receipt No.
Received by Date
'331
PERMIT VALIDATION
PERMIT NO. 2331
DATE APPROVED 3-23-95
EXPIRATION DATE
3-25-95
DATE i.,;,;t I FF D A 3-23r95
ByIga b
/WV ► ---
A inistrative Authority
Recorded by 11 TELEPHONE: (619) 564-2246
igna
re of Applicant or Agent
Greater Coachella Valley Soap Box Derby
P. . B 1305 La Quints.
92253 (619) 345-1101
Name of Applicant (please print)
Bus'
ess Address
Telephone No.
Lucia Moran
(619) 564-3761
Name of Contractor and Job Foreman
Business Address
Telephone No.
Contractor's License No. City Business License No.
Great American GLP 7--01-22-01-01
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Class 111
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $
Permit Fee
0
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $ —0
Receipt No.
Received by Date
'331
PERMIT VALIDATION
PERMIT NO. 2331
DATE APPROVED 3-23-95
EXPIRATION DATE
3-25-95
DATE i.,;,;t I FF D A 3-23r95
ByIga b
/WV ► ---
A inistrative Authority
Recorded by 11 TELEPHONE: (619) 564-2246
NOTE:
With proper validation
this form constitutes an
encroachment permit CITY OF LA QUINTA
APPLICATION FOR PERMIT
-PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water trains
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
S
OATS: Subdivision Improvement Permit — Claes III
Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION R
(Street addre s or Oescription of Location)
D�SCRI
DIMENSION OF INSTALLATION OR REMOVAL
a
Sketch (attach construction plansIM
tt�)
( ®F LA QLUNT'A'
SIZE OF EXCAVATION, IF NEEDED
APPRO I TE TIME WHEN WORK WILL BEGIN ZS 5
APPROXIMATE TIME OF COMPLETION 7�/95,
ESTIMATED CONSTRUCTION COST S
(Including removal of all obstruction, materials, and debris, backfilling, com-
paction and placing permanent resurfacing and/or replacing improvements)
In consideration of the granting of this permit, the applicant hereby agrees to:
MAR 2 2 1995
PUBLIC WORKS
Indennnifv,-defend end save the CItV. its authorized agsms, officers, representatives and employees, harmlels from and against carry and all
Penalties. liabilities or Ion resulting from dames Of tour action and arising out of any accidans. los or damage to parsons or prop"
happening or occurring as a pnoairiata rmn of any wort undvtakan under the Peri( granted pursuant to this Applbtion.
Notlfy the Administrative Audhority at least twenty-four (ice) hours in advance O the when waft will be stared,
Comply wid+ all appliceble City Ordinances, the, coma and conoro o} . rt all applkable rule aed r�ulatiau �0 Gty a
La Oulnts and to pay for carry additional repkaartynt neon y es mutt era I // %
tura of Applicant or Aom
X 'Lc t ��nht how -A Q 130 e0%• q�Z ��-3?�
L
Nae of Applicant (please print) Susi Address Telephone No
X G c�a
k__061.cue a 150 )e;�C
Name 0. Contractor and Job Foreman 5" :mss F ddrass F Teieph6re No.
Contractor's License No. City Blisinen License No.
'1 P -r -+Z X G UP —7—c)j Z Q
Applicants Insurance Company 11516U. LIAgIL—ITY Policy Number
FEES: Subolvision Improvement Permit —Class III'
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $
Permit Fee
Penalty
Cash Oeposit•Surety Bond
if required
TOTAL: $
Receipt No.
Received by Date
Recorded by f
�o
1386
PERMIT NO.
PERMIT VALIDATION
33 /
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
7
TELEPHONE: (61916442M.
'
o
'../:1�1��II. CERTIFICATE O_ F_ INSURANCE DATE (MM/DD/YY)
03-13-95
PRODUCER - -� - - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
`�. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
BRLZM GOODHUE C OOKE C RX4Z AGE!TCY INC -HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
544 WHITE POI`ID DR STE A ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
A -KK N OH 44320 -COMPANIES AFFORDING COVERAGE
COMPANY
A GREAT AMERICAN
INSURED
COMPANY
INTEEMATIOML SOAP BOX_ DMY INC
B
COMPANY
P 0 BK 7233-
AKRW CH 44306
C
COMPANY
D
COVERAGES - - -- - -- -- - - - --- - - -
- -
THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE (MWDD/YY)
POLICY EXPIRATION
DATE (MWDD/YY)
LIMITS
6ENERAL'0WgiL(TY
' ,� $, r
i� i R
GENERAL AGGREGATE,
�-
-
PRODUCTS-COMP/OP AGG $ +
A
COMMERCIAL GENERAL LIABILITY
; 7-•01-22-01-01
5/18/94"
5/18/95
PERSONAL & ADV INJURY $
CNIMS MADE OCCUR
EACH OCCURRENCE $
OWNER'S 8 CONT PROT
FIRE DAMAGE (Any one fire) $
i}et•
MED EXP Any oneperson) $
AUTOMOBILE
LIABILITY
2
COMBINED SINGLE LIMIT $
ANY AUTO
,
BODILY INJURY $
ALL OWNED AUTOS
SCHEDULED AUTOS
.r
(Per person)
BODILY INJURY
$
HIRED AUTOS
NON -OWNED AUTOS
(Per accident)
PROPERTY DAMAGE $
GARAGE LIABILITY
♦
AUTO ONLY - EA ACCIDENT $
OTHER THAN AUTO ONLY:
ANY AUTO
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY
EACH OCCURRENCE $
AGGREGATE i $
RUMBRELLA FORM
+, $
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
STATUTORY LIMITS
EMPLOYERS' LIABILITY
EACH ACCIDENT $
THE PROPRIETOR/ INCLy
r
-
DISEASE - POLICY LIMIT $ -
PARTNERS/EXECUTIVE
REXCL
DISEASE - EACH EMPLOYEE $
OFFICERS ARE:
OTHER
B
Special Risk
45SR750381 Participan
12/01/94
2/01/95
250 Dental. Limit
idental
45SR750382 Volunteer
/94 -
2./..0.11/95
S,,.0.100 4LA=icbnt�aal� Death
1,1..2/01
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
,5.1,
j ficate holder(S) named below shall be n additional
Certificate
i lSponscrrship,
insured as pertains to the Lioanseee,,, or running of your All American Soap Box
Derby Event to be run on the following dates:
QSr
CERTIFICATE HOLDER '99rj_ _ _ - V ____ _ CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
t+e� t��t� 7t M7�t�
BE: CREAT dDA=Z A VAUM 1A)A BOX MMY
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
THE CITY OF Laqj=A, 222 - CGUB PALM 3o- DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
SPRINGS, THE DESERT WIM PUBLISHING BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
aD, cormy cuma IS ai OF C uxFomm,OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
A DIV OF THE PROVIMCE JOURNAL OD, AUTH ED REP E NT IVE
ACORJY�( 9)
®ACORD CORPORATION1993