5107Finance Revenue Code E-1
ENCROACHMENT PERMIT
PUBLIC WORKS CONSTRUCTION
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.
Subdivision Improvement Permit - Class III
Minor Improvement Permit Class IV
DATE:August 7, 2006
LOCATION OF CONSTRUCTION (Street address or Description): Smith Residence; 51-425 Madison Avenue
PURPOSE OF CONSTRUCTION: PM10
DESCRIPTION OF CONSTRUCTION: PM10; See PSN 06128
DIMENSION OFINSTALLATION OR REMOVAL: PM10
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APPROXIMATE TIME WHEN WORK WILL BEGIN:August 6, 2006 TIME OF COMPLETION:August 7, 2006
ESTIMATED CONSTRUCTION COST: $2,000.00 (Including removal of all obstruction, materials, and debris, backfilling,
compaction and placing permanent resurfacing and/or replacing improvements)
COMMENTS: See Permit Number 5139- rough grading for single family dwelling
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 at (760) 777-
7075.
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules and regulation th City .
of La Quinta and to pay for any additional replacement necessary as the result of this work.
FYI
Signature of Applicant or Ageno Vkv,
Shively Construction - Jeff Shively P.O. Box 1096 La Quinta CA 92247 (760) 275-4333
Name of Applicant (please print) Business Address Telephone No.
Same as above
Name of Contractor and Job Foreman Business Address Telephone No.
440810 6453
Contractor's License No. City Business License No.
Pro Builders Specialty Insurance Co. WES5010420
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit - Class III
Minor Improvement Permit - Class IV
Inspection Fee
Permit Fee
As -Built Deposit
Cash Deposit -Surety Bond,
if required.
TOTAL
$NA See #5139
$NA See #5139
S
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$No Fee
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
See attached schedule
PERMIT NO.5 1 O%
DATE APPROVED: �6
EXPIRPVI�JC�i.pATE:. —J
BY: `v\
Administrative Authority
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PUBLIC WORKS DEPARTMENT
APPLICATION FOR PERMIT
Date: _Y''`t-Q 6
Tract No: Project Name: S_res•�e e
Vicinity: J� 1— 4 z5
Purpose of Construction (i.e.: Rough Grading, Offsite Street, etc.) P%'l
Description of Construction (i.e.: See Plan Set No. 01234) Phi., PS N 06 (Z g
Dimension of Installation or Removal:
Approximate Construction Start Date: S- 6 -()6
Approximate Construction Completion Date: 7— 0 6
Estimated Construction Cost: $ ZO 0 J
Estimated Construction Cost shall include the removal of all obstructions, materials, and debris, back -filling; compaction and
placing permanent resurfacing and or replacing improvements
Contact Name: eSS ' S1,.; _,t� . Phone Number: Z 7S - (33 3
Name of Applicant/Owner: (fie pe-,
Applicant Address: VO o x q G a- C A q ZL't
Applicant Telephone Number: 2.7 5 - K 3 3.
Applicant E-mail Address:
Name of Contractor: �-� a y ��• {�,�
Contractor Address:
Contractor Telephone Number:
Contractor State License Number:
Contractor City Business License Number:
Contractor E-mail Address:
►A COPY OF THE CURRENT INSURANCE CERTIFICATE MUST BE PROVIDED 4
Applicant or CQontractor G/�-eneral LiabiillJi►ty Insurance Company: % / .
Applicant or ntractor General
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Office Use Only:
Inspection Fee: �j Lk
Permit Fee: A '�
As -Built
Deposit:
Dust Control
Deposit:
Credit
Amount: , r
TOTAL FEE DUE:
ty Insurance Policy Number:
Office Use Only:.
5i3c\ Assigned Permit Number. O�
3c( Approval Date:
Expiration
Date:
Issue
Date:
Administrative Authority:
FOR PERMIT.doc
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