Loading...
529 (2)SIZE OF EXCAVATION, IF NEEDED APPROXIMATE TIME WHEN WORK WILL BEGIN. APPROXIMATE TIME OF COMPLETION ESTIMATED CONSTRUCTION COST $ (Including removal of all obstruction., materials, and debris, backfilling, com- paction and placing permanent' resurfacing and/or replacing improvements) 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 connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS / `�/ %� Subdivision Improvement Permit —Class I.1I DATE: c T— Minor Improvement Permit Class IV LOCATION OF CONSTRUCTION (Street address or Description of Location) PURPOSE OF CONSTRUCTION ���%���—�—�� Sketch (attach construction plans if appropriate) DESCRIPTION OF CONSTRUCTION DIMENSION OF, INSTALLATION OR REMOVAL _ �aIry .0 s♦ rrru 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 Admirdstrative 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 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 I I 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 $ Permit Fee G Penalty . Cash Deposit -Surety Bond if required TOTAL: $ Receipt No. Received by Date Recorded by t?OTA 3 i1S-9Q 10.00. f 0 PERMIT VALIDATION PERMIT NO. DATE APPROVED EXPIRATION DATE DATE .ISSU r TELEPHONE: (619) 564-2246 nistrative Authority NOTE: 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 Subdivision Improvement Permit — Class II I DATE:- �!� Y / / �2 Minor Improvement Permit Class IV LOCATION OF CONSTRUCTION (Street address or Description of Location) PURPOSE OF CONSTRUCTION`` f'a '„��%'�'' Sketch (attach construction plans if appropriate) DESCRIPTION OF CONSTRUCTION 2 DIMENSION OF,INSTALLATION OR REMOVALt'�%���� SIZE OF EXCAVATION, IF NEEDED APPROXIMATE TIME WHEN WORK WILL BEGIN APPROXIMATE TIME OF COMPLETION 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 (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 i d �� _Sd: a -� . "" ���~ ' !/`/` fib/ f ��,e /i'9✓ f > /� `'.%', Name of Applicant (please print) Business Address Telephore No. Name of Contractor and Job Foreman Business Address Telephone No. : Contractor's License No. City Business License No. ; r Applicant's Insurance Company Policy Number FEES: Subdivision Improvement Permit — Class I II 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 Date Recorded by C -1a4< (0TA1. 2 i o. 0 PERMIT VALIDATION PERMIT NO. DATE APPROVED EXPIRATION DATE DATE ISSUED By! Z, + ` A frninistrative Authority +fd�� TELEPHONE: (619),564-2246 ;,Ut _I Co _ ciy C.__ I Kr4`Ei- .. ,,_ ., I � • .... .....::.. , . •.. .. J l3fUC Oit7£ (rXFA COYr} .,.... .' AS A MATTER O INPOr�hiAYly !'1NLY htlG CON, ER. :. ! 90.COUCZ.g1 THIS. CEAYIFjOATE IS ISSUED VMFiCA-rF HOLDER., IIIIS CERTi'r,CKI CCcS NOT At;1`C,NQ. . } CtSH C. ����9wN;D ,;O RluHTS L'?ON.THE 0R ALT VR THE C6`vE IAGE AFFOFDEO ElY THE POLL-=-$ 3ELt7tiV Q.O. 13OX 5788 �SA'�a' IrRi�Apc)INO, CA 024�12•5783 �Gi��ANtE� A�,��JFlO91V� �t3�lE��i�� T L:' (714) 889-9811 *f THE HOMEI[\+JEMMITY COiAFAi y k t 0.° LEMACOMPaN [ { ifv�1J'c�•NCE CO?'iPr1hY i GOWA IN6uNKa . COMPntiY c I I,MSE Y SAND .G ROCK CO ccTTER 1p . 0. goX 1767 COrrsPar:'r ' 11DIO, .CA 92202. LETTCA COMPANY �'c ..._ . LE.TTEp _ Vt� H; i'd'3UREO NA,N LZ ABUVi: FUSS "Yic P`, LICY YEFIOD 'r1:7H RE°f'CT.Tv y HiL'H THIS `:SURANCF, L��TEG 8SLOW HAVE r5E ; 'S'� la TOT PC)LiCiES C:F TriiS IS TO;Cc�'fiFY THAT THE �' A:3'e r.WUUi? e+'•EtdT,'TEnI•� AR C:aNC1f10N c , r Are : CGN f ACT On 07;7_ . ObCL'��'� r� �?� r Gr' HEFIF,IN IS SVBjS<;? TQ ALL Tiife Tf:RPlS, L'ESC- "!ND'GATS& NIGr''iIiTHSTAND:rG _ fi iCATE AY 8E I$SUEp r,'6t tiiF�Y ?EfiTAItJ. THS IN,;,U •A �= F"rOnJEO S`f Tt;E pr_i 1WiCS + v - N 1=_�i1:CFa BY P`,:, CLAI"�S. Pi:./� dEE Cyr �XC USipNS`Rr.0 CON01'SONS JC SUCH PO'_IC!FS. LIMITS �t:JWN MA" It T He�ay,el;i CO 'R^ +=E P•)UCY NUMOR, vq_t�v EFFEC't'vE o- LIr,Y EXP,ra':=" a-L LIMY$ pATr ;MMiOAi[{I 7ATp (N.MiCG T[RE OG Ir13 'Llft r ,t ,GENE?n�; AGGftEC+ATE g sO0{; PROOUCYS C' . %pS n &I R£GATe S 2,00 ih OM .iEACiAL +GEr4L'k'AL,JA$iLITY - P4i13C•'%:iL 8 aL'i'R" >'.NO IN:UFY S 1)`ICL " X F6` CtyIMSMnDC occur;. {ii�R9D86�'r�5 9/-I/89 yj �� °� x 2,000 U: OWMER'S & CONTRAC'OR'5 PROT, n CC FIRE j4nL4?J- (Any ene `•4-0 IL EXpcNss .. ".y i'j Jitti Jf' S .� O a lTOAt08tL'e LFAO:LtTY 2Oti0 LIIdIT ANY AUTO?27 �• 1 Q 6091aY 9/1/3% 7/ 1 GAF 63s'7C HIAEO AUTOS, (Pp, L LAM1-+� .. E E �ck AG _,A 3r.- STATV'YOAy ' WORKER'S tOb?�•aitATiON ^ �nnr 0 ^ .,fin- !t ..,i�"•'•.'�;•t --s�. '�� :�07. 9� 1/ 7�. 5 1 r�rVt , -A :% - t� ANC Yn .'yyoDiv iiU� ;it EMP'_ch F'r:S' 004UTY OTHER 1 .: n c:fll37R.'.:JN`:iSP:C,AI AT ... ... .Lt� - . CE5:.>;:?':Gti •:'v OP_PA f!0NS,!LilCC t " , :E7dS. ___.. CANCELLATION CEfiifFlC/S7E HOLDER sMcuLD ANY OF, HE ,�q� :E DGS+-%. iE'. ?C ri •`� BE Cr!'''"•_.r.0 LOO�-1TY OF RIVERSIDE ; EY,PIAA'':bN OAT T:tE;+EGF, 7NE 15S'rlNr c0,r! j Q SOX O9'' tAAll vA'�S ,4RITIEN rvG710E TO THE CERTiF CAi . I LE LEFT. BUT FAILIU 4b TO null SUCH NOTrCP Sn LL 'ilai ZSE . i . , V'1tIECO 9?1D:'Y, 17$ a�nf� C'Q iicr r L rib IITY OF ANY K•ND UFt�' ^ . I �y �_� a -.iG"s �J,�.-y-f�o•'T'iCT �y Y� �f/ +~ o 46,i �!�, . r1 1 _5 �, �fn�•S"w Y i p,s �`�.l"f ih 'l.?}[•N tT�So S a�:.