2900NOTE'
With prbpdr validation
this form constitutes an
encroachment permit
CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
Ror 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
DATE: 2111/99 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 2 tel M.H.S. E/S. of Washington, south of Miles Ave.,
& 2 tal. M.K.&. on W/S of Washington north of Miles Ave.
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Re—adiunt M.H.S. to Grade
Aue to nee streets
DESCRIPTION OF CONSTRUCTION R & 'R. Alanhalt. raise
WE- 14A, "i. r-h- ring.
DIMENSION OF INSTALLATION OR REMOVAL 80' asuhalte
t-ntn1 xt All fnur l.ac.n>eions.
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN 2/16/99
APPROXIMATE TIME OF COMPLETION 4t16/99
ESTIMATED CONSTRUCTION COST $ 1.1100.Off
(Including removal of all obstruction, materials, and debris, backfilling, com-
paction and placing permanent resurfacing and/or replacing improvements)
Sketch (attach construction plans if appropriate)
In consideration of the granting of this permit, the applicant hereby agrees to:
SEE ATTACHED CONDITIONS.
k
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 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.
c
Signature of Applicant or Agent
�s t 11201 Hnrral St. Mira Loma, CA (909) 360--7000
Name of Applicant (please print) Business Address Telephone No.
,pv.^"k Mi lnnr- J (760) 343-3334
Name of Contractor and Job Foreman Business Address Telephone No.
17ASA7 1182
Contractor's License No. City Business License No.
ClArendoan America Innurance Co. TNC0698980129
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 100.00
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $ 1no.0n
Receipt No. Received by7� SL- Date �dplyJ
Recorded by
2900
PERMIT VALIDATION
PERMIT NO. 24110�
DATE APPROVED 7/17/49
EXPIRATION DATE 4/30/99
DATE
ISSUED
% Administrative Authority
Telephone: (619) 777-7075
SPECIAL CONDITIONS --PERMIT NO. 2900
--- Re -'adjust Manholes. to Street Grade (Washington St. s/o Miles Ave.) ---
In, addition to the standard permit conditions, the following shall apply-
Pursuant to Section_14.16.320 of the La Quinta Municipal Code (Ordinance 10 § 1 (part), 1982), all
work shall be performed in accordance with the latest edition, of the Standard Specifications For
Public Works Construction (SSPW-Q and" as directed by and to the satisfaction of the City Engineer.
HCI Inc„ hereinafter referred to as "Permittee' ; shall be responsible for providing continuous dust.
and erosion control:
3 .
Streets shall be kept clean. They, shall be completely cleaned at the end of, each working day and
more frequently if required.
4. Pursuant -to Section 6.08.050 of the La Quinta Municipal Code (Ordinance 18 § 1, 1982), throughout
the work site, the Permittee shall comply with City regulated work hours., Operation and maintenance
of equipment within one-half mile of human occupancy shall be performed only during the following
time periods:
1
October.
2
5.
6.
lst to April, 30: `Monday -Friday- 7:06,a.m. to-5:30 p.m:
Saturday 8:00 a.m. to 5:00 p.m..
- May 1st to September 30: Monday, -Friday 6:00 a.m to 7:00 p.m.
,Saturday 8:00 a.m. to 5:00 p.m.
Work shall be prohibited on legal holidays and Sundays
Work performed within 500 feet of a signalized intersection is restricted between the hours of 9 a.m.
- 3 p.m: Traffic control shall be set up after 9 a.m. and removed before 3 p.m.' The Permittee shall
contact the Riverside Country 'Traffic; Signal Maintenance Department at (909) 275-6894 if signal
.operation, at the, intersection is to be altered in any way.
Pursuant to Section 14.16.110 of the- La Quints Municipal Code (Ordinance 10 § 1 (part), 1982),
Permittee shall assume responsibility for repair of any pavement damage to any public or private
street and for any damage to other City streets or facilities as a: result of work performed under this
ermit _
7. Pursuant to Section 14. l 6.250 of the La Quints Municipal Code (Ordinance 10 § 1 (part), 1982),
advance warning. signs and traffic control shall be installed, and maintained in' accordance with Cal
Trans Standards or the Work Area Traffic Control; Handbook (WATCH Manual). A traffic control
plan, if required, shall be prepared in accordance with the. WATCH Manual and submitted to the City
'for review and approval one (1) week prior to starting any construction. It shall .be the Permittee's
responsibility to appropriately detour and barricade all construction sites.
.Special Conditions -Permit No. 2900
Pagc l of 4
v
SPECIAL CONDITIONS--PERMIIT NO. 2900
--- Re -adjust Manholes to `Street Grade (Washington St. s/o• Miles. Ave.) ---
8. 'Pursuant to Section ,14.16.290 of the La Quints Municipal Code. (Ordinance 10 § 1 (part), 1982),
street closures shall not be permitted. A minimum, of one travel lane of paved -surface shall be
maintained with flagmen at all. times.
9. Prior to excavating, if required, the Permittee shall contact Underground Service Alert at 1=800-422-
4133. It shall be the Permittee's-responsibility to notify the Public Works Department of anticipated
excavation which impact City facilities, including but not limited to traffic. signal, conduits and loops;
irrigation lines, electrical conduits, and storm drain facilities.
10. Should additional work, materials, or modifications of the work be requiredin order to meet City
standards, safety requirements, signage requirements, or to fit actual field conditions, the work shall
be performed- by the.Pdmittee..as..directed. by and: to: the. satisfaction of the. City. Engineer at; no. cost,
to .the City of La Quinta..
11. Pursuant to Section 14.16.370 of the La.Quinta Municipal Code (Ordinance 10 § 1 (part), 1982),
backfill compaction within street rights -of -way shall conform with Section 306-1.3 of the latest
edition of the Standard Specifications For Public Works Construction.(SSPWC), except as otherwise
specified herein.
Native material may be,used as backfill material provided that minimum compaction, achieved in the
manner prescribed herein, is achieved. Backfill shall be performed by mechanical means; 'no water
densified compaction via jetting or flooding- or other means shall be allowed. It shall be the
Permittee's responsibility to provide appropriate geotechnical supervision, testing, and inspection,
onsite, at all times during backfill operations.
Backfill compaction shall be achieved by the following conditions-.
A. When a firm foundation is not encountered' due to soft, spongy or other unsuitable material,
such material shall be removed to the limits directed by the Geotechnical Inspector and/or the
City Inspector and the resulting excavation backfilled. with pipe. bedding material..
B. Backfill materials shall be brought to or maintained .at an appropriate moisture content for
compaction. The appropriate moisture content range shall be established at the onset of the
project and ensured prior to use of the materials through progress testing on the stockpiles.
C. The first length. of trench backfilled shall- be.backfilled in the presence of the City Inspector.
Compaction shall be tested'.at random depths at, approximate three-foot vertical intervals as
backfill is placed to ensure the effectiveness of the compaction methods and to establish the
depth of lift that can.be compacted.
D. If lifts greater than one foot are attempted in this trial length of trench, compaction tests shall
be taken within the lifts to ensure that the full depth of the lift is compacted. Upon satisfactory
completion of this portion of trench, .the City Inspector shall establish the maximum lift
thickness to be compacted for the remainder, of the project.
Special Conditions - Permit No. 2900 Page 2 of 4
SPECIAL CONDITIONS --PERMIT NO. 2900
--- Re -adjust Manholes'to Street Grade (Washington St. s/o Miles Ave.) ---
E. In subsequent lengths of trench, the frequency of compaction tests shall equal one per each lift
of backfill, per 300 linear feet of open trench, at randomly selected locations within the open
length of trench.
F. The depth of the randomly selected compaction tests shall also be randomly selected except
that where multiple tests are required in, a given length of trench, the tests shall be no closer
than three feet. (vertically) from each other. ;
G. If any compaction test fails, previously.placed backfill- (in the same length of open trench or
previous lengths of trench) which is represented by the failing test (as determined by the City
Inspector), shall be tested for compliance with compaction requirements.
H. All costs incurred due to the conditions above shall be borne.by the Permittee. Copies of all
test results shall be furnished to the City Inspector.
12. All excavations within City of La Quinta right-of-way shall be backfilled, and temporarily paved if
within the existing travel. way, at the end of every, workday as directed by and to the satisfaction of
the City Engineer for the protection of the public. Lengths of open trench shall not greatly exceed
that which can not be backfilled in the same day. Excavated trenches shall not be allowed open
overnight, however, Permittee may leave a length of excavated trench, not to exceed twenty (20) feet
in length, open overnight at a point where construction will begin the next day, provided that this
length of trench is completely covered by steel plating.
13. Ail landscaping, irrigation,'decorative rock, decorative concrete, lighting, etc., shall be replaced to
its original condition..
14. Access and egress to all local properties shall be maintained at all times.
15. Pursuant to Section 14.16.375 of the La Quinta Municipal, Code (Ordinance 10. § 1 (part), 1982),
permanent pavement replacement shall be completed no later than seven (7) days after the completion
of the work. Permanent pavement replacement shall conform to the following conditions:
A. Existing asphalt concrete,pavement shall be sawcut one (1) foot' be-yond trench edges. Edges
shall be straight and clean. _
B. Permanent pavement replacement structural section, within all trenches, shall be 1 thicker than
existing of asphalt concrete over.the same existing thickness of,crushed aggregate base or
crushed miscellaneous:base, meeting the requirements of Sections 200-2:2 and 200-2.4 of the
Standard Specifications for Public Works Construction. The replaced pavement and base
material shall be compacted to 95% relative compaction and respectively tested, for each 300
linear feet of trench:'' Verify exact structural replacement section thicknesses with the City prior
to installation:
Special Conditions- Permit No: 2900 Page 3 of
SPECIAL CONDITIONS --PERMIT NO. 2900
• --- Re -adjust Manholes to Street Grade. (Washington St. s/o Miles Ave.) ---
C.. Permanent pavement. replacement shall be installed using a City approved 3/4" max medium
_asphalt concrete as the base course lift and a City approved t/2" max medium finish course lift
for capping. Asphalt°concretemix design shall be approved by the City prior to its placement.
D. For, transverse trenches across improved streets, the existing pavement surface, three (3) feet
on either side of the excavated trench, shall be cold -milled to a depth of 0.10, with a "butt"
joint created along each edge of the cold -milled area, and a new 10.1.0' lift of.'/2" max medium
asphalt concrete pavement overlay applied throughout, the cold -milled area.
E. For longitudinal trenches within improved streets, the existing pavement surface, through the
lane width (within lane line striping), shall be cold -milled to a depth of 0.10', with a "butt" joint
created along each edge of the cold -milled. area, and a new 0.10' lift of/2" max medium asphalt
concrete pavement overlay applied throughout the cold -milled area.
F. If grinding and capping operations are not performed in the same day, as base paving
operations; the base course lift of 3/4" max medium asphalt concrete shall be installed from saw
cut edge to saw -cut edge flush with the existing street surface. The base course lift of paving
shall not be left 0.10' low in anticipation of grinding_ an&capping,
F. Any existing lane striping affected by this resurfacing shall be replaced in kind by the Permittee,
as directed by and to the satisfaction ofthe City Engineer. Affected traffic signal loops shall
be removed and -replaced in kind. The finished, pavement surface shall be smooth, consistent,
and shall conform to the surrounding grades.
16. Permittee shall notify the City of La Quinta Public Works Department, Mr James Lindsey, a
minimum of 48 hours prior to commencement of any construction -at (760) 777-7075.
17. Permittee shall stabilize any soil that was disturbed (shoulder areas, etc.) as a result of work
performed under this permit with an approved dust control treatment.
18. ,. Pursuant to Chapter 12.56 of the La Quinta Municipal, Code (Ordinance 10 § 1 (part), 1982) the City
'has designated certain city streets as Truck Routes. The weight.limit.for restricted streets (i.e., streets
not part of the Truck Route network) is three (3) tons; trucks exceeding the weight limit may use a'
restricted street if making a delivery or pickup.on the subject street, or if this permit specifically grants
permission to use the street to deliver street construction materials and/or equipment.
19. The City. of La, Quinta reserves the right to revoke, suspend or void this permit at any time. `
20. Stock pile: shall not exceed 3' in total height from the existing surrounding area.
21. Stock pile, shall . be permanently stabilized with "an approved material at the completion oT the,
operation.
'Special Conditions - Pcrmit.No, 2900
Page 4 of 4
f
R• •
NOTE:
With proper validation
this form constitutes an CITY OF LA QUINTA
'encroachment permit S
APPLICATION FOR PERMIT'
PUBLIC WORKS CONSTRUCTION, (ENCROACHMENT) v
C�MOF Tl$°
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
DATE: r Q �� 9" - a Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 2 TEL- ht.k{j 5 OF WAS4I4l6TU7V, 50u7N OF
t
aril ES • Z Ttl._ M-I+S om w/S aF WASNWbtoly NORt4 aG M1'�ES
"(Street address or Description of. Location) • -
PURPOSE OF CONSTRUCTION RE - A04%AST - )`14S TC1 Sketch (attach construction plans if appropriate)'
l rLAIDE, ALe-A-SI: OF NEW l S1'0.EI`TS
DESCRIPTION OF CONSTRUCTION R- ASV 1I LT,
F-AIS C M.M L111D , ILEVLAa %.4-A-TVk
C6mc_VLETE_ 11-1Vj —
DIMENSION OF INSTALLATION OR REMOVAL AO' ASp lA ALT, r
y'e TA L-_ AT. ALL - T 6%AR- Lot_14116nfi
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME. OF COMPLETION -
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:
Iridemnify,-defend -and save the City, its authorized agent.s, 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 permit and all applicable rules and regulations of the City.of
La Quints and to pay for any additional replacement necessary as the result of this work.,
Signature of Applicant or Agent
11zo1 "AiLML-. ST-, AtILA 'LamA 46q-366--2'130o
j Name of Applicant (please print) Business Address Telephone No.
-FILAN K mi L." ILA- 766- 343 - 333-4 .
Name of Contractor and Job Foreman Business Address , Telephone No.
3� S 87 i 1 s 2
Contractor's License No. City Business License No. -
Applicant's Insurance Company' Policy Number
FEES:. Subdivision Improvement Permii — Class III t
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule 2774.
Inspection Fee :$ // PERMIT VALIDATION
'Permit Fee 1 PERMIT NO.
Penalty
Cash Deposit -Surety Bond DATE APPROVED
if required EXPIRATION DATE.
TOTAL: �$' =/OO^ _ `T•y DATE ISSUED
Receipt No.
By
Received by Date Administrative Authority
Recor6d by Telephone: (619) 777-7075
•
.S,UBSTRUCTURE /JNFRACTION•NORKSHEET:+
.RELEaSE�.
- . INSTRUCTIONS: This•forn�is-to �be' used for cork associated with incidental
FEB 0.4 1999
buried/subtructure-activity not associated iith a cork order
(raising MR,lids; potholing,.°etc:). Also used for Division.
requests and,,clear ngJafractions not•charged #' Repair.
PRINTED,ON 02/04/99
1'.10:03:43, BY: M.BRADLEY ..
1 LOCATION: WASHINGTON ' ST S/0 MILBS AVE
J MAP NO.
I LC 0549.I10: 0903NS'
11 [ -(.CORRECTION OF I DATE CUT SHEBTS REA. I SERVICE ORDER N0. (if involved),,"I
I. RECORDS ONLY?- I I JPA
b I/{
N0. 'I -DATE WORK COMPLETED I
4
$
I DESCRIPTION:,RAISI MH LIDS ^
F-=
I CTRL NO. 990135
I CREATION DATE:.02/11/99 : 1 -'DATE REQUIRED: 03/11/99 1 RCVD IN OPCEN: / / `"` I,: RLSD TO CONST:'
I
I REMARKS
IDENTIFIED
WORK' 9TY' NOTBS I
I.MH'Grade.Adjustment ............ '2 1
1 ' RAISE N 635 & MH636' TO �ROADGRADE. COOLEY CONST `HAS MARKED LOCATION. OF MHS I 1
`UNDER
I ASPHALT:
I
.
,. �I FIRM? [ N I- PERMIT?-MAINT
f
. I SUPV: - I PREPARED BY: , M.BRADLBY
I, TELO ( 760.778-3603.1
RC/BC: I DATE: -� I
5TATii OF CALtFOANIA
DEPARTMENT OF INDUSTRIAL RELATIONS
OFFICIR OF THU DIfMECTOR
NUM
CERTIFICATE OF CONSENT TO SELF -INSURE
HCI, INC. to California corporation)
'PHIS IS TO CERTIFY That SuWidiary of Sol iaa - Certiffeate No.. 2
206
bas Conspired with the requirema* of the Director of Indaswd Relations =der the b t>ed tb icw f
Sections 3100 to '3705, inclusive, of the LA r Code of the State of California an y
Certificate of Cwsent to Self -Insure.
This certificate may be revoked at any time for good cause shown.°
rtnseTrva IMP T Of 1ND AL RELATIONS
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annatiee tti surfs ea�]o�ar or Ida t is el>wffe of the a due ee ft aanow fat then to arort to aaooaedW�
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NC)UVSNMV#00 SA1331HOM
Contractor's State License Board - License De...
Page I of 2
STATE OF CALIFORNIA
CONTRACTOR'S STATE LICENSE BOARD
P. O. BOX 26000
SACRAMENTO, CA 95826
PHONE. 1-800-321-2752
* * * DISCLAIMER * * *
The license status information shown below represents information taken from the CSLB licensing data base at the time
of your inquiry. It will not reflect pending updates which are being reviewed for subsequent' data base updating. The
available information may not reflect any civil or criminal judgments or actions that have not been reported to the CSLB.
lfthere are disclosable complaints (legal actions) on the contractor's license, that information will be provided. If you
intend to pursue any kind of legal action. insure you get a "Verified Certificate" which is a certified license history
covering a specific time period prior to taking any action.
Extract Date: August 05, 1998
TI I:E RESULTS OF YOUR INQUIRY FOR CONTRACTOR LICENSE NUMBER 378587 IS:
*.BUSINESS INFORMATION
HCIINC
P O BOX 487
MIRA LOMA, CA 9.1752
Entity: Corporation
Issue Date: 07/17/1979 Expire Date: 07/31/1999
* * * LICENSE STATUS * * *
This license is current and active.
* * * CLASSIFICATIONS * * *
C-7 LOW VOLTAGE SYSTEMS
A GENERAL ENGINEERING CONTRACTOR
* * * CONTRACTOR BONDING INFORMATION * * *
I'his license has bond number 25343594 in the amount of $7,500 with the bonding company
SEABOARD SURETY COMPANY.
Effective Date: 05/01/1994
* * * WORKERS COMPENSATION INFORMATION * * *
1"his license has workers compensation insurance with the NATIONAL UNION FIRE
INSURANCE COMPANY OF PITTSBURGH, PA
Policy Number: 4157856 Effective Date: 06/15/1997 Expire Date: 06/15/1998
Click on Personnel List
to see the people on this license.
THIS IS THE END OF YOUR INQUIRY RESPONSE.
QUESTIONS ABOUT YOUR :DATA SHOULD BE DIRECTED TO 1-800-321-2752.
http://www2.cslb:ca.gov/iXpress/CSLB_Library/CSLB+Book/License+Detail.DML 8/5/98
Contractor's State License Board - Personnel ..: Page 1 of 1 w
PerSonnel List
` for License, Number 3 7858 7
Click on the person's'name to see a more detailed page of information on that person.
Name
Title
Association
Disassociation
Class
More
'
Date .
Date
Class
MONGER, LLOYD I
VICE
PRESIDENT
• 07/17/1979
07/27/1983
BARNARD, ROGER K'
S/T .
05/24/1989
07/15/1991
GRINDER, DANIEL,
' �
,
EDWARD '
�O/p �
09/10/1987
C-7
More
STANTON, LINDA LEE,
SECRETARY
07/17/1979
07/27/1983'
EMERY, JAMES WILMONT
VICE ' •
PRESIDENT
09/10/1987
05/24/1989
ARMSTRONG,'KENNETH
HOUSTON SR
RME
12/12/1991
11/30%1992
A
MC INTIRE, TERRY. JAY
RMO/CH
06/08/1983
01/13/1989
DOS
MONGER. LARRY WILLIAM'
RMO/P
07/17/1979
12/31/1982
D05
WELLS, BOBBY•GLENN
S/T.- -:
07/27/1983 .
05/24/1989
MONGER. MICHAEL LEE
TREASURER
07/17/1979
07/27/1983
BARTZ, ELMER ROBERT
VICE '
09/10/1987
-05/05/1993
PRESIDENT
CI-IAMBERLIN RICHARD
JAMES '
PRESIDENT
09/10/1987'
05/24/1989
NORTON,SANDRA-
ANGELINE
V/S/T :
07/15/1991,
CASH. BRUCE EDWIN
VICE
05/05/1993
03/19/1998
PRESIDENT '
SIL•AGI, STEVEN GERARD
VICE -
PRESIDENT
,03/19/1998
ROBERTSON. MARION
VICE
PRESIDENT
03/19/1998 ,
.
EARL ,
Return -to' the Personne'l.Name Reguest'j:Contractor Name Request License Request or �,o to
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y BUSINESS LICENSECERTIFICATE NOT TRANSFERABLE
CITY OF IA QUINTA
The Licensee named herein having paid to the City of La Quinta all fees required, I icense is hereby granted said Licensee to transact the PLEASE POST INA
business herein set forth, for the period stated in conformity with the Provisions of Ordinance Na 2 of this city. This license Is Issued CONSPICUOUS PLACE
without verificatipp��y�hp theJ see is subject to or exempt k % y the State of California
F R PERIOD UiS/b6/�� TO •�flM BUSINESS/LICENSE NO. 1182
WC: 11201 HARRELSSTBF.ET
MBA LOMA, CA 91252
TYPE OF BUSINESS
11201 BARBEL STREET
MBA LOMA.- BA 91252 GENERAL. -ENGLUMLING
CONTROL NO. 03800
1. Business Name: µ- •�
2. Business Address: 11-to 1 NA IP-11L S T M MA LO#%A cry g125Z
3. Mailing Address: 11Y01 ViARItjEL ST 1A4RA LOMA CA 411292
4. Business Phone: (90�) ' 366-1 DO O
5. Owned By:. . CORPORATION' PARTNERSHIP INDIVIDUAL
6. If Corporation or Partnership, Tax I.D. #:
7. If Individual Owner, Social Security #:
8. Name of Owner or Officers and Title: BAN 6111w.0EL f Pit OEry-r
9. SBE Resale Number:
10.- Number of Decals Needed:
11. ' - CONTRACTORS ONLY: Copy of State Contractors License Pocket Card Is Required. -
Type of Contractor: GfAifRAu ENGINCEitluC,
Classification: c -7 — A V
C. State License Number: -3-1 85 8 7 U -
A or B License Classification 00 Per Year or $50.00 Semi'Annual 1 V
C License Classification $ 50700 Per Year or S25.00 Semi -Annual
I HEREBY CERTIFY that all the information supplied by .me is correct and any licenses required by the
County, State or Federal Government have, been -issued to me and are in full force and effect.
Signature Title Date
Send.Completed Form To: CITY OF LA QUINTA
BUSINESS LICENSE DIVISION
P.O. BOX 1504
La Quinta, CA 92253 ',.
AUG 0 6 1998
N TA