4072Hi
F
NOTE: �
a With proper validation P
this form oonstitutes.an CITY OF LA QUINTA
encroachment, permit
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
C�MOF T69�rt`'
For the construct'io'h '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 II I
DATE: 1/27/04 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 81805 Ave. Juarez and CALlle Sinaloa
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Paying Only Repair Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION 3'::3' in 3"man. South side
Calle Sinaloa 121' West of center line of Ave Juarez
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN 2-29-04
APPROXIMATE TIME OF COMPLETION 1 day
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:
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 124) 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
Le Quinta and to pay for any additional replacement necessary as the result of this work.
Signature of Applicant or Agent
Califronia Gas: PO Boa 3603; Redlands, _CA-92373;_909-335-796.3
Name of Applicant (please print) Business Address Telephone No.
A.M. Ortem 10125 Channel Rd: Lakeside, CA: 619-390-1988
Name of Contractor and JobForeman Business Address Telephone No.
4RFi4tt 04114
Contractor's License No. City Business License No.
Gas Company Self Insured .
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Class III
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
i if required
TOTAL:
i` Receipt No.
Received by
Recorded by
$ 100.00
Date
N2 4072-
PERMIT VALIDATION
PERMIT NO. gym?
DATE APPROVED 1-28-04
EXPIRATION DATE 2-28-04
DA IS D -Z$-O
By L
Administrative Authority
Telephone: (760) 777-7075
01/28/2004 14:23 FAX 7GO7771233 LA QUINTA COMM. DEV.
16 001
TRANSMISSION OK
TX/RX NO
DESTINATION TEL #
DESTINATION ID
ST. TIME
TIME USE
PAGES SENT
RESULT
*********************
*** TX REPORT ***
0868
919093357527
01/28 14:21
0116
3
OK
CITY OF LA QUINTA
PUBLIC WORDS
DEPARTMENT
FACSIMILE TRANSMITTAL. SKEET
O: SANDRA GAS COMPANY
AM 909-335-7527
ITEM: PERMIT FEES FOR CITY OF -LA QUINTA
FROM: DATE: WE DNE SDAY,
AnhonyCol=ssi, JANUARY 28, 2004
Assistant Engineer I
The following 2 pages contain the permit fees per permit
issued.
Thanks, Tony