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DATE: 04/03/2003
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TO: VICTOR MONZ FAX: (760) 777JJ55
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` CITY OF. LA QUIN'T~A{
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PUBLIC WORKS/ENGINEERING
•l., 1' 7'8-495 C A L L E TAMPICO ?
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LA' QUINTA, -CA 9 22 53
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_ FACSIMILE, TRANSMITTALSHEET-
T - FROM.
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COMPANY: DATE: '
' FAX NUMBER: �' , Y TOTAL NO. OF PAGES INCLUDING COVER --
PHONE NUMBER: SENDER'S PHONE NUMBER: '
3 4-6 7-4-e) . 760-777-7075 2�5 Z1�
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" SENDER'S FAX NUMBER:'
760=777-7155.
URGENTOR REVIEW ❑PER YOUR REQUEST ' ❑ PLEASE REPLY ❑ PLEASE RECYCLE , ?
MENTS:
'NOTES/COM_ 1
C /0�0LL �nl
s- 'MAILING,'ADDRESS: P.O. BO•X 1504. LA'.QUINTA, -CALIFORNIA 9,2253
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NOTE: '
With proper validation '
this.form.constitutes-this - _..-...'.._...... :._...-._..._-.._.._...._ y «`
—
;. CITY OF LA' QUINTA
encroachment permit-
h . APPLICATION FOR PERMIT ,'
f PUBLIC WORKS CONSTRUCTION (ENCROACHMENT),
' For the construction,of public of private curbs, driveways, pavements, 'side4lralks, parking lots, sewers, -water mains ;
- and oth"'like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
J , t r4 ... r«r 1 - .., • µdi+. • -' -. � ��. ' 'C. y.
/ a Subdivision ovement Permit —Class III ,
DATE: — /imp/covement Pelmit Class IV
"• LOCATION OF C NST UCTION
(Street address or Description of Location) '.
PURPOSE OF CONSTRUCTI
�[d Sketch (attach construction plans• if appropriate)
• i' " DESCRIPTION OF CONSTRUCTION
i M DIMENSION OF INSTALLATION OR REMOVAL
a ;i.V
4 S` SIZE OF EXCAVATION, IF NEEDED '
-Y,27=s + r,
j, APPROXIMATE TIME WHEN WORK WILL BEGIN d a
APPROXIMATE TIME OF COMPLETION — ��®�' n * y '
ESTIMATED CONSTRUCTION COST $
i f "(Including removal of all obstruction, materials, and debris, bachfilling, com '-
:t pection and placing permanent, resurfacing, and/or replacing improvements)
- •. In consideration of the granting of this permit, the applicant hereby agrees to: ;•. ^ : k' .H v
Indemnify. -defend and save the City, its authorized agems, officers, representatives and employees, harmless.fron['and against any end all
penalties, liabilities or'loss resulting from claims or court action and arising out of, any accident, loss or damage.to persons or pro"
r;r happening or occurring as a proximate reiult of any work undertaken under the permit groomed pursuant to this application. c _
f, Notify the Administrative Authority et least twenty-four (24) hours in advance of the time when ,will be started. � L, ,•, ,;
•i Comply with all applicable City Ordinances, the terms and condition of the permit an a li rules and regulations of,the City of •
La Wnta and to pay for any additional replacement neeessary'es the "M of this rk.
Signature of Applican Agent .` }
Name of Applicant (please print) Business Address « Telephone No.
Name of Contractor.and Job Foreman Business Address ' Telephone No.
' Contractor's License No. City Business License No.
Applicant's Insurance Company GEN. LIA611.ITy Policy Number
' FEES: Subdivision Improvement Permit — Class I I
Public improvements: 3% of estimated construction costs -
Private improvements.: 3% of estimated construction costs —AL .t f
Minor Improvement Permit — Class IV: See attached schedule r y t k
` Inspection Fee $ a ; ' - - PERMIT VALIDATION'
Permit Fee Y PERMIT NO.:,:fi '
~ " Penalty
+' Cash Deposit -Surety Bond DATE APPROVED
if required a .EXPIRATION DATE a t'
' TOTAL: $ N-0
s , DATE ISSUED
Receipt No.
By
Received by 'Date �n p� p in Administrative Authority
ir' �Z ► �'15
.�. Recorded by. TELEPHONE: (619) 777775 '
J
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The ,
Gas
Company Patrick W. Doane
Field Planner
A'Sempra Energy -company Distribution
75095 MayfairDrive, SC8652, Palm Desert, CA 92211-5102
Tel:760.346.4248 Fax:760.773.9243
Hours: 7:00-8:00;am - 2'.30.3:00 pm
1