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this form oono��uum'a�
' ' CITY ���� �/� �K�8����^
�encroachment � ' ' ` ^
APPLICATION FOR PERPN|l[ ou
^ � PU0LI`C WORKS CONSTRUCTION /EyACROACHK8F��\
. ' . —''' '
^ ' For the construction of public or private curbs, driveways, pavements,' id4wu|ks', parking lots,
- � and� / \Um pvWiowu,ks.imp,ovomonmin �thK8(NOR|K8PROVE(NENTSand APpR ^ DSUBD|V\S0 �S- ~ �'
. ~ . . . . , . . . . ' .. `,
Minor,__ Subd� C�sU(
DATE:
. .
LOCATION OF CONSTRUCTION 119
(Street address or Description of Location)
Backbone feed for tract -
PURPOSE OF CONSTRUCTION Sketch (attach construction plant. if appropir iate)
ff CONSTRUCTION
SEE ATTACHED FOR'GENERACPROVISIONS
'AND SPECIAL.CONDITIONS.
Above
DIMENSION OF INSTALLATION OR'REMOVAL -3. A -RIVERSIDE COUNTY PERMIT,WILE AUSO BE,'
S12E OF EXCAVATION, IF NEEDED 1136.(SEE,ATTACHED)
APPROXIMATE TIME WHEN WORK WILL BEGIN -
APPROXIMATE "TIME OF COMPLETION -
EST IMATED CONSTRUCTION COST $
placing improvements)
paction and placing permanent resurfacing and/or re
In -consideration of the granting of this permit,, the applicant hereby agrees:to:
Inclemnify,A�f6nd and save the City, 4s authorized agents, officers, representati�es"ancl employees, harmlesi f rom and against any and all
penalties, liabilities or 'loss resulting from claims or court action and arising out of,any accid I ent, loss or clar�age 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 AutKority at least tw.enty-four.(24)'hours in advance of the time when work.will be started.
ComplV'with 'all applicable City Ordinances, ' the terms and conditions of the permit and all applicable rules and regulations of the CitV,of,
La buinta-and to pay for an-Y additional replacement -necessary as the result of this work.
I Signature of'Applicant-or Agent
GTE CALIFORNIA 83 (619)342
Name of AlSplicant (pl�ase print) Business Address Telephone -No.'
Name of Contractor and Job Foreman It Business Address Telephone No.
Contractor's Lic ense No.. City Business License No.
"Applicant's, Insurance Company Polidy Number
Public improveriients: 3% of estimated construction costs
Minor Improvemint Permit — Class IV: S6e attached schedule
Inspection Fee $ PERMIT VALIDATION
DATE APPROVED
Cash Deposit -Surety Bond
.'. .. .
/ Rooei N
,. ^ , , ~' '
.Receivedby Date
N ^ Recorded bv~. �
Itibutu
By U`7
Administrative Authority
TELEPHONE: (61Q)GO4-2246,
. . `
NdTEI
With proper validation
this form constitutes an CITY OF LA QUINTA
encroachment permit
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
1./19/90 Subdivision Improvement Permit — Class II I
DATE: Washington St. W/S N/0 Miles Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Backbone feed for tract
W?3971 DEANE HOMES It
DESCRIPTION OF CONSTRUCTION ri aCe LWU iu. aniU A i.0
IlVrltl01Ea dl1ci (r7e S� a� j� - o ( a-u-•, Xi 2 " )
DIMENSION OF INSTALLATION OR REMOVAL wuuvli�
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION . - •��
ESTIMATED CONSTRUCTION COST $ Lu,wv.vu
Sketch (attach construction plans if appropriate)
$. 5EE ATTACHED DRAWING "AV
REFERENCE: Q.0.649-71r12-I
. SEE ATTACHED FOR GENERAL PROVISIONS
AND SPECIAL CONDITIONS.
3. A RIVERSIDE COUNTY PERMIT WILL ALS" BE
REQUIRED.(SEE CONDITION R38).
4.IF CONTRACTOR O'HER THAN (ATE SEE COVITIC
R36.(SEE ATTACHED}
(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.
Signature of Applicant or Agent
GTE CALIFORNIA 83-793 DR'. Carreon Blvd., Indio, Ca. 92201 (619)342-0535
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 Policy Number
FEES: Subdivision Improvement Permit — Class III
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs N0 510
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by Date
PERMIT VALIDATION
510
PERMIT NO
1/19/90
DATE APPROVED
7 31/90
EXPIRATION DATE
DATE ISSUED 1/19/90
By—
Administrative..`2„�'�. 'l
Authority
Recorded by
TELEPHONE: (619) 564-2246
04 "
�C%
78-105...CALLE ESTADO `— LA. QUINTA, CALIFORNIA- 92253 -' (619) 564-2246
FAX (619) 564-5617 -
ADDITION --=-ENCROACHMENT PERMIT NO.510-=--CONDITIONS
Survey monuments shall be protected in place or -
sre.established..pursuant to -City standards'And the.State of
California Land Surveyor's Act. _
-Contractor shall -comply with the'local noise ordinance and
-.construction operations and maintenance of equipment within
-one-half mile' of. human: occupancy .shall be performed only
during the time. periods as follows:
October 1st to'Apri1.30: Monday -Friday 7:00a.m.-5:'30p.m.-
Saturday 8:00a.m.-5:00p.m.
May -.1st to September,30:1 Monday -Friday 6:00a.m.-7-:00p.m.
' Saturday. 8:00a.m.-5:00P.m.
Work-shall.be prohibited -anytime on Sunday or Federal .
holidays.
R35 Traffic control shall be as per.Cal Trans Traffic Manual.
Field adjustments in.detouring shallibe•accomplished as
directed in order to adjust to actual field conditions. It
shall be the contractor's responsibility,, -,to adequately
barricade and detour this site.
R36 If work -'done by other than work forces .of General.
•'Telephone Company, -then an initial.`inspection fee deposit
shall.be made as determined,by City„'Engineer. Permittee
shall.'reimburse City for�.all inspection costs at the rate
of.$35.00 per hour., (Note: estimate one hour.per day
during the construction. period.).. Any unused funds will•be
reimbursed. `
R37 All' excavation at or near the -travel way .shall' be `
backfilled at the'end-of the work day, for the protection of
the traveling public. '
938• This permit issonly for work within the City.of.La Quinta
public,street right-of-way.,'A Riverside County Permit will
also 'be required.
R39 Ingress and egress for local properties shal-1 be maintained
at all times. _
R40 This permit is;not valid unless the USA Inquiry Number -is
noted on the'. City' copy, of this permit.
F R41 Replacement pavement shall be existing asphalt thickness
plus one inch, but not less than-3 inches`of AC pavement
shall be.placed. Class•2:aggregate base shall be as per
existing or 6" minimum (whichever is greater) for
arterial streets.) `
MAILING, ADDRESS;- P.O. BOX 1504 LA QUINTA, CALIFORNIA 92253 ~.
�/ O
'
The f0wing General and Special Provisions are attached to and maeart of Permit No.
GENERAL PROVISIONS
The following shall always apply:
• t r
ENCROACHMENT ON PRIVATE PROPERTY: This permit authorizes work to be accomplished within City of La Quinta right of way
�°
ONLY. Whenever construction extends within private property, it shall be the responsibility of the permittee (or his contractors) to
r secure permission from abutting property owners. Such authorization must be secured by the permittee prior -to starting work.
'
TRACKLAYINGCONSTRUCTION EQUIPMENT: Cleated tracklaying construction equipment shall not be permitted to operate on any -
paved surface unless -fitted with smooth -faced street pads. All mechanical outriggers shall be fitted with rubber street shoes to protect
the paving during excavations. Rubber -tired equipment only shall be used in backfill operations in paved areas. If the existing
•
pavement is scarred, spalled, or broken during the term of this contract, or if the pavement is marred, City of La Quinta shall request
-
that these portions of road be resurfaced over their entire width. Resurfacing shall consist of one coat of two inches (2") of A.C.
surfacing plus appropriate seal coat as specified above. " 4
PROTECTION OF TRAFFIC: All excavations and -work areas shall be properly lighted and barricaded as deemed necessary bythe City
Engineer or La Quinta City Public Works Inspectors. Suitable detours and detour signs shall be placed and maintained for the duration
of the project. The City shall be notified 24 Hrs. in advance of any traffic detours or delineations.
-
CARE OF DRAINAGE STRUCTURES: Any drainage structure including corrugated• metal pipe, concrete pipe, steel culvert and
concrete'structures encountered during excavation which necessitate removal shall be replaced in kind. In the event:it becomes
necessary to remove or cut existing drainage structures, City of LaQuinta shall be notified prior to commencement of this work.
'.r, Drainage structures and open drains shall be kept free of debris at all times for proper drainage.
! j
RIGHT OF WAY CLEANUP.: Any surplus material resulting from excavation and backfill operations shall be' removed from the right of
way. All paved surfaces shall be broomed clean of earth and other objectionable materials immediately after backfill and compaction.
Existing gutter line and drainage ditches shall be replaced to their original standard or better. All excess material shall be removed
prior to paving. Water tanker shall be used, as required, to sprinkle the job site to keep down dust conditions and shall be used
..
-
immediately after backfill. ,
r
DE=WATER OPERATIONS: If de -watering operations are required and pumps are forcing water on City of La Quinta roads, it shall be
the responsibility of the permittee (contractor).to control this water and to provide off-street barricades when necessary.
'
CLOSING STREETS: No street shall be closed. A minimum of one lane of traffic shall be maintained at all times to provide limited
access for the adjoining property owners and emergency vehicles. In the event it isfeltbythe permittee that he mustclose a streetfor
any length of time, permittee shall contact this office to obtain the necessary permission.
SPECIAL PROVISIONS r
'
The follwing shall apply ONLY when indicated:
`
R1 NOTIFICATION:-Permittee shall notify the City at 564-2246 at least 48 hours in advance of starting construction.
R2 CASH DEPOSITS OR BONDS: A cash bond or an approved surety bond in an amount of not less than $ +
„4 • shall be furnished in the name of City of La Quinta to coverall work involved in the restoration of the various La Quinta '
r'
roads and survey monuments. This bond shall be continuous until cancelled by the City Engineer. This bond must be
posted prior to commencement of any work on this project .
UTILITY CLEARANCE: (Substructures) Prior to making anyexcavationwithin the City ofLaQuinta right ofway authorized .
Jr ,
by permit,.the permittee shall contact all concerned utility companies relative to the location of.existing substructures.
_
Damage to existing substructures resulting from operations conducted under this permit shall be the sole, resp6Rsibility
of the permittee.
r
R4 UTILITY CLEARANCE: (Surface structures) No work shall be done under this permit until all utilities'are clear of the
proposed work site. The permittee shall notify all concerned utility companies of the proposed work.
' •�, t''
R5 PAVEMENT WIDENING: Area between the proposed concretegutterline and the existing road pavement shall be
surfaced with r " inches of A.C. paving placed on inches of class aggregate subbase course
having an"R"value of not less than -and in conformance with City of La Quinta Road Improvement Standards
"and Specifications, Ordinance 9461.'
R_6 -PARKWAY GRADING: Area between.the property line and top of the proposed concrete curb shall be graded to a slope of
1 /4 inch to one foot (11. ,
R7 GRADES' &ySTAKES: City. of La Quinta shall establish grades and stakes for the proposed concrete curb and gutter
construction.
R8 GRADE CHECKING: CityofLa Quinta shall check grades upon receipt of plan and PFOfile and/or grades as established by
a licensed engineer. "
R9 CURB REMOVAL FOR DRIVEWAYS: A portion of the existing concrete curb and/or curb and gutter ( feet)shall be
1 r
t + removed. Curb and/or curb and gutter shall be saw cut prior to removal. Depressed curb, matching -concrete gutter and
t
concrete driveway approach shall be constructed in conformance with City of La Quinta Standard #207.
'DRIVEWAYS,
R10 A.C.: Driveways shall be constructed as,not to alter existing drainage pattern. Surfacing between the
property line and the existing road paving shall be 2-1/2 inches of A.C. paving placed on (-") of class
aggregate base. Driveway construction shall conform to attached drawing. .
�..
R11 CULVERTS: A inch diameter( )culvert shall be installed with the invert approximately)-1/2
_
inches below and in line with the existing flow line. Culvert installation shall conform to the attached drawing.
SIGHT CLEARANCE: Sight clearance of 600 feet in either direction shall be assured and maintained.
R13 SOIL STERILIZER: The area to be surfaced shall be.treated with soil sterilizer.. Rate of application shall comply with the
r manufacturer's specifications.
R14 COORDINATE WORK: The proposed work shall be subordinated to any operation which the State of California or
'City of La Quinta may conduct in this area during the period of this permit. Work shall be coordinated with the State or
: • �.', * 'r• City of La Quinta forces to preclude delay or interference with State or City of La Quinta projects.
„r
R15. SURVEY MONUMENTS: Prior to excavation or beginning of construction, all survey monuments which exist on the
centerline of all streets or property lines when involved shall be completely tied out so they may be readily and correctly
be replaced by a licensed civil engineer, or surveyor at the expense of the permittee. A complete set of notes showing the
„ .
ties to these monuments shall be furnished to the City Engineer prior tothe removal of any monuments. This office shall.
„-
be notified upon completion of replacement of all survey monuments for proper project clearance.
RD-31 t'
SURVEY MONUMENTS: Prior xcavation or beginning c truction, all sui , monuments shall b'etiedoutbyCity
of La Ouinta and suitable payment or guarantee of payn tall be made as reimbursement for all work involved.
H1 PAVEMENT CUTTING: Pavement will be mechanically cut to a straight edge prior to excavation. Method of pavement
cutting shall be approved through the office of the City Engineer. (Under no circumstances shall excavating equipment
be used to excavate prior to cutting of pavement). Excavation material shall be placed in such a position as to best
facilitate the general flow of traffic. Prior to final paving operations, any damage to pavement straight edge shall be
corrected.
R18 PAVEMENT CUTTING: Pavement shall be saw cut prior to removal. Prior to final paving operations, any damage to
pavement straight edge shall be corrected.
R19 LIMIT OF EXCAVATIONS: Excavations shall be limited to 1,000 lineal feet of open trench before backfill operations must
begin. All excavations shall be properly barricaded with lights overnight, on weekends and holidays for the protection of
the traveling public. The Public Works inspector shall determine the suitabilityof excavation barricading in each ease. No
excavation shall remain open for a period exceeding five (5) days. No excavation shall be made unless the construction
material is actually on the work site.
R20 BACKFILL MATERIAL: Backfill shall be free of brush, roots or other organic substance detrimental to its use for purposes
of producing an adequately consolidated backfill. Any material which the City of La Quinta deems unsuitable (spongy or
saturated material) which is encountered during excavation shall not be used for backfill, but shall be supplemented or
replaced by an approved sand or gravel.
R21 BACKFILL SAND: Backfill shall be approved transit -mix sand or equivalent and shall be placed in lifts of not greaterthan
three feet (3') and vibrated using vibrotamper or equivalent equipment. Alternate methods may be substituted, but in any
case a relative compaction of 95 percent shall be attained within the structural section of the roadway.
R22
BACKFILL PLACEMENT: Backfill shall be applied in layers of not more than 50 percent of the total depth of the trench
before flooding or a maximum of five-foot (5') lifts where trenches are of excessive depths. Care is to be exercised that the
backfill material is not subjected to extreme swell by flooding operations. Backfill material shall be placed so that the
resulting compaction shall be not less than 90 percent or equivalent to the surrounding ground, whichever is the greater
compaction. Where ponding or flooding is used for a maximum settlement, adequate dikes will be constructed to retain
the water. Where jetting is used, the jets shall be of sufficient length to reach the bottom of each layer and the water
supply shall be continuous.
R23
COMPACTION TESTS: If so required bythe inspector, compactiontests shall be made at intervalsof not more than 1,000
feet and a minimum of one (1) test on each road. One (1) copy of each test shall be forwarded to the City Engineer for
approval and filed prior to making permanent repairs. Compaction tests shall be made as outlined in Section 6.3.01 of the
Standard Specifications, Division of Highways. State of California, dated January 1973.
R24
COMPACTION TESTS: If so required by the inspector, compaction tests shall be made for each crossing or service line.
One (1) copy of each test shall be forwarded to the City Engineer for approval and filed prior to making permanent repairs.
Compaction tests shall be made asoutlined in Section 6.3.01 of the Standard Specifications, Divisionof Highways, State
of California, dated January 1973.
R25
TEMPORARY PAVEMENT REPAIRS: After completion of backfill and compaction operations, a temporary patch
consisting of 2 inches of SC-800 shall be placed on a prepared subgrade. The SC-800 temporary paving shall be placed
after a maximum of 3,000lineal feet of trench has been excavated and backfill operations completed, but in nocase shall
R26
the placement of the temporary pavement exceed a five (5) day limit.
PERMANENT PAVEMENT REPAIR: After backfill and compaction operations have been completedy temporary patch
at f
consisting of two inches (2" of SC-800 shal be laced immediately. A permanent pinches A.C.
surfacing placed ona_ inch class base shall be placed no later than days after completion of
temporary road repair.
R27
PAVEMENT REPAIR: F.A.S.: Upon completion of backfill and compaction, a temporary patch consisting of two inches (2")
of cold mix paving (SC-800) shall be placed immediately. A permanent patch of three inches (3") of A.C. surfacing shall
be placed on six inches (6") concrete base as directed, but not later than fifteen (15) days after completion of temporary
_
paving. Concrete base shall be of five -sack mix and shall conform to the City of La Quinta Road Improvement Standards
and Specifications, Ordinance #461.
R28
FOG SEAL: A fog seal coat consisting of an application of asphaltic emulsion shall be applied over all patch alias as
determined by the City Engineer.
R29
SEAL ARMOR COAT: A seal coat consisting of an application binder and screenings shall be applied on all patch areas
where such seal coats existed prior to issuance of this permit. Seal or armor coats shall be applied as specified in Section
37, Standard Specifications, State of California, Division of Highways, dated January 1973. Work of pavement repair to
be accomplished by a licensed contractor engaged in the business of pavement repair.
R30
STREET RESTRIPING: Where street striping is still visible on streets to be excavated, such striping shall be replaced upon
completion of permanent repairs.
R31 TREE RELOCATION OR REMOVAL: Tree relocation within the City of La Quinta road right of way shall be accomplished
by a licensed, bonded and insured tree service, and handled safely without interference or hazard tothe traveling public.
It shall be the responsibility of the permittee to maintain the tree in a vigorous growing condition at its new location.
Trees to be removed shall be removed in sections which can be handled safely without interference or hazard to highway
traffic. The entire width of the tree stump shall be removed and disposed of so that no debris remains in view of the
highway. The stump hole shall be backfilled and thoroughly compacted as specified in the following paragraph. Where it
becomes necessary to restrict traffic, the work shall be restricted to a maximum of 500 feet at any one time. Adequate
signs, flagmen and/or barricades shall be provided to protect the traveling public at all times.
Large holes resulting from tree removal shall be backfilled and compacted to not less than 90 percent or equivalent tothe
surrounding ground, whichever is the greater compaction as determined by the impact or field method. Compaction
tests shall comply with Section 6.3.01 of the Standard Specifications, Division of Highways, State of California, dated
January 1973.
R32 TREE TRIMMING:
a. Only the necessary trimming shall be accomplished to provide clearance of the facility for one calendar year.
All broken or weak sections within the trimming shall be removed.
b. Where it becomes necessary to restrict traffic, the work shall be restricted to a maximum of 500 feet at anyone time.
Adequate signs, flagmen, and/or barricades shall be provided to protect the traveling public at all times.
c. If tree trunks are partially outside of the City of La Quinta road right of way, permittee shall make his own
arrangements with adjoining property owners for consent tothe trimming in addition tothe authorization provided
by this permit.
d. All tree trimming on EVERGREEN TREES, PALM TREES, and other ORNAMENTAL TREES shall be accomplished to
the satisfaction of the City Public Works Inspector.
e. Abutting property owners shall be contacted, in all instances, prior to trimming or topping trees.
f. Pruning shall, in all instances, be at the shoulder of the crotch to insure even, fast healing in all cuts of two inches
(2") and above in size. Sealant shall be applied to all cut sections as directed by the City Public Works Inspector.
NOTE: —'�--
With proper validation
this form constitutes an
encroachment 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 connectiori with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
REFERENCE: W.O:#549-71812-I
Subdivision !mnr;e;yar-:.Permit'- Class lii'
DATE:�_.ddnUdry 1;6, 1990 - Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION.- Washington St W/5 N/O Miles
(Street address or Description of Location), -
PURPOSE OF CONSTRUCTION back bone feed for, tract Sketch'lattach construction plans if appropriate)
23# 971 DEANE HOMES
DESCRIPTION OF CONSTRUCTION . PI -ace tWo 10.k' X 5 X
manholes and one concrete slab 5 x- x 7 ,See attached drawing "AA"
DIMENSION OF INST.-',LLATION OR REMOVAL above REFERENCE: W.O.#549-718127I
®���� �o �
SIZE OF EXCAVATION, IF NEEDED N e^Q�� I T �t�/(�(Dw� Y-"
S�eC ,ru Co^di rt ah S.
APPROXIMATE TIME WHEN WORK WILL BEGIN 3-19-90 3c A. �"Ve R-S i GCf�, Cci%^`t %y
APPROXIMATE TIME OF COMPLETION 5-1 - 0* e.-
ESTIMATED CONSTRUCTION COST $ 16 , 000. 00' ��(jv 1 ��2�' ,�Sc�, CD'"r' ,� T I one
(Including removal of all obstruction, materials, and debris, 6ackfilling, com-
paction and placing permanent -resurfacing and/or replacing improvements) ' C��
In consideration of the granting of this permit, the applicant:he-riaby"agrees to.;..,,
Indemnify; defend and save the City, its 'authorized agents, officers, reoresentatives and emOlayees, harrniess --y a ed 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 thisapplication.
Notify the Administrative Authority at least twenty-four (24) hours in advance of the time ,,when _work will. -bet 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 94 this work.
Signature Applicant or Agent , �-/
GTE CALIFORNIA 83-793 DR Carreon Blvd., Indio, C . 92201 619:/0535
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.
i
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
if required
TOTAL:
Receipt No.
Received by
Recorded by
Date
PERMIT VALIDATION
l
PERMIT NO. �1 O
DATE APPROVED. _
EXPIRATION DATE / —1
DATE ISSUED �[CIO� q
i
By
Administrative Authority
TELEPH•ONE:16 0) 564.2246
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