39061
NOTE: '
With proper validation
this form constitutes an.
encroachment permit
CITY OF ,LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION, (ENCROACHMENT)
F.or the7 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 II
. DATE: Midy 13, 2003 Minor Improvement Permit Class IV
LOCATION' OF,CONSTRUCTION Madison Street• sewer tie-in from the Grlf•Mainteuance
Buil4lu?, Tract 29834
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Sewer tieI*in Sketch (attach construction plans if appropriate)
DESCRIPTION OF,CONSTRUCTION 6" sower litre installuioaa
and. :backf ill
DIMENSION OF INSTALLATION OR REMOVAL As u¢eded
SIZE OF EXCAVATION, IF NEEDED As neaded
APPROXIMATE TIME WHEN WORK WILL BEGIN May 15, 2003
APPROXIMATE TIME OF COMPLETION May 22, 2003
ESTIMATED.,C.O.NSTRUCTION COST $ -1.1,800.00
(Including removal of alfobstruction, 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 -permit and all applicable rules and regulations of the City of
z
La' Quinta .and to pay for any additional replacement necessary as the result of this workf
Signature of Applicant or Agent
Thel ie�eaaiway `( in Wi]�li,r�nal) 81w100 Avenue 53; La Quiuta { 60) .275-9328
Name;of,'Applicanf• (please print) Business'Address Telephone No.
' C.J.U. • Conotrueti®n ,•• 831 S.—State Street, San .Jacinte, CA. (909) 487-•120:1
Name of Contractor and Job Foreman Business Address Telephone No.
.75267:4-
Contractor's License No. City Business License No:
Applicant's Insurance Company Policy Number n _ f1
FEES: Subdivision Improvement Permit —'Class II 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 $ 354;00
Permit Fee 100•00
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $ key+.vv
Receipt No. '
Received by Date
Recorded by
MAY 14 2003JLI
CIFINANCETY OF LA QUINTA
DEPT.
sa*
PERMIT VALIDATION
-PERMIT NO. 3906
DATE APPROVED Mav 13. 2003
EXPIRATION DATE May 31, 2004
DATIF I SUED ✓"�t, �l\.� 13,
1'Byy,I 1C'�n.��. l.1-�..�� � •
Administrative Authority
Raoul Maitirserl, AssinVant Engineer II
Telephone: (760) 777-7075