3734 (2)m --- --s _ ____�__
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NOTE.,,
With proper validation
this form constitutes an
encl'oopchment 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
DATE:August 30, 2002
Subdivision Improvement Permit — Class I I I
Minor Improvement Permit Class IV XZ
LOCATION &-CONSTRUCTION CIP project ---Jefferson Street Landscape Median Project
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Trench repairs.
DESCRIPTION OF CONSTRUCTION Saw —cut demo and export
100 If of'existing AC uavement
DIMENSION OF INSTALLATION OR REMOVAL 100 If x 1811 deep
widt'kr an neadsd
SIZE OF EXCAVATION, IF NEEDED 100 £t, x L5 ft x 1.5 £t
APPROXIMATE .TIME WHEN WORK WILL BEGIN SAInitember 3. 2D02
Sketch (attach construction plans if appropriate)
**All work to be performed per the
General Contractor's contract with
City of La Quinta.
APPROXIMATE TIME OF COMPLETION AS workino AAvs
ESTIMATED CONSTRUCTION COST $ NA
(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;lwill 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.
Signature of Applicant or Agent
Kemp & Kemp Services PO Box 733 -Thousand Palms, CA 92276 760 Q.1229
Name of Applicant (please print) Business Address Telephone No.
Curtis hemp same as.above
Name of Contractor and Job Foreman Business Address Telephone No.
687487 03941
Contractor's License No. City Business License No.
Evanston Insurance . CL041701558
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 -Surety Bond
if required
TOTAL:
Receipt No.
$ NA
$ NA
Received by Date
Recorded by
J 8734
PERMIT VALIDATION
PERMIT NO. 3734
DATE APPROVED August 30, 2002
EXPIRATION DATE December 1, 2002
DATEISSUED August 30, 2002
By -OCL4
Victor Monz Administrative Authority
Telephone: (760) 777-7075