4216NOTE: r
With proper validation
this form constitutes an
encrc;achment permit
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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 I P VEMENTS and APPROVED SUBDIVISIONS
Subdivision Improvement Permit— Class III
DATE: August 31, 2004 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION Intersection of Washington St. and Ave 47 behind curb
. . 11�
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Lower Vault (Utilities) Sketch (attach construction plans if ap
propriate)
ppropriate)
DESCRIPTION OF CONSTRUCTION Lower Vault75ehind aid wank
Due to a change in grade
DIMENSION OF INSTALLATION OR REMOVALEhind curb
approximately 10'40'
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SIZE OF EXCAVATION, IF NEEDED r
`APPROXIMATE TIME WHEN WORK WILL BEGIN 9/07/0 SEP 0 2�;�}APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $ 1,500.00 ITYOF (uR�tjjNA
FINANCE DEFT
(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 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
La Quinta and to pay for any additional replacement necessary as the result of this work.
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Signature of 'Applicant or Agent
Time: Warner Cable 41-725 Cook Street, Palm Desert, CA. 92211
Name of Applicant (please print) Business Address Telephone No.
Cochran Communication Construction 36630 Cathedral Canyon Drive, CC 93324
ff �. _,.,_. t
amt oVontractor and Job Foreman Business Address 00865 Telephone No.
Contractor's License No. City Business License No.
Fred Sadeghi Insurance Services LHA126303
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 $ 6600
Permit Fee 100.00
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $ 100.00
Receipt No.
Received, by Date
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE ( f
DATE ISSUED\
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Administrative Authority
Recorded by
Telephone: (760) 777-7075