3733s
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, sidewplks,.parking lots, sewer's, water mains
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
DATE: August 30. 2002
LOCATION OF CONSTRUCTION CiP ProJeCt* La
Subdivision Improvement Permit — Class I I I
Minor Improvement Permit Class IV x
uinta Civic Pa
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Installation of (2) each
3" conduits
DESCRIPTION OF CONSTRUCTION
install
backfill and comuact.
`'"DIMENSION OF INSTALLATION OR REMOVAL
Pat- the contract documents
Sketch (f ad'--, u ion plans if appropriate)
a8 performed in strict
acc ce with the contra4t documents
he by the General Contractor with
the City of La Quinta.**
SIZE OF EXCAVATION,`IF NEEDED as needed
i
APPROXIMATE.TIME WHEN WORK WILL BEGIN Seatember 3., 2002
. APPROXIMATE TIME OF COMPLETION 43 working dotvA
ESTIMATED CONSTRUCTION COST $ 9.000.00
(Includin6'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, de?end• and save the City, its authorized agents, officers, representatives and employees, harmless from and against any and all
i 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, t
Notify the ,Administrative Authority at least twenty-four (24) hours in advance of the time,when work will be started. i
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applica/rulend regulations of -the City of
La Quinta and to pay for any additional replacement necessary as the result o this work. +'
Ignature of Applicant or Agent
Tri Star Excavation PO Sax 542 Cathedt4l CCity,(• CAS .760.321.0898
Name of Applicant (please print) Business Address Telephone No.
Laryy Owens/Chuck Hurt sate as above
Name of Contractor and Job Foreman Business Address Telephone No.
47730 A/B 00762
Contractor's License No. �rv4E City Business License No.
State Fund ,rri7701Va���...., 044-400I9798
rj►L : �'i'O.Oooc
- /
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Class I I I
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 Deposit -Su rety.Bond
if required
TOTAL:
Receipt No
Received by
$ NA
NA
$
Date
PERMIT VALIDATION
PERMIT NO. 3733
DATE APPROVED August 30.r 2002
EXPIRATION DATE
DATE ISSUED
December 1, 2002
August 30, 2002-
By
Victor Mont Adinistrative Authority
Recorded by
Telephone: (760) 777-7075
0
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