CIP2016-0003Titq~,4- -4 Q"
ENCROACHMENT PERMIT
PUBLIC WORKS CONSTRUCTION
See below for Finance Revenue Codes
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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.
DATE: 7/6/2016
LOCATION OF CONSTRUCTION (Street address or Description): 79120 BLACK HAWK WY
PURPOSE OF CONSTRUCTION:
DESCRIPTION OF CONSTRUCTION: LA QUINTA PARK / CIP RESTROOMS/ C1P2013-12
DIMENSION OF INSTALLATION OR REMOVAL:
PROXIMATE TIME WHEN WORK WILL BEGIN: TIME OF COMPLETION:
ESTIMATED CONSTRUCTION COST: (Including removal of all obstruction, materials, and debris, backfilling, compaction and placing
permanent resurfacing and/or replacing improvements)
COMMENTS: EE PROJECT CONTRACT AND SPECIFICATIONS FOR CIP 2013-12 FOR PERMIT CONDITIONS
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 indertaken 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) 777-7097. To
submit an inspection request, leave a message on the Inspection Request Hotline at (760) 777-7097 prior to 1:30 P.M. at least twenty-four
(24) hours prior to the anticipated inspection.'
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicab ations of the City of and
to pay for any additional replacement necessary as the result of this work.
nt or Agent
THREE PEAKS CORP
Name of Applicant (please print)
THREE PEAKS CORP
Name of Contractor and Job Foreman
941528
Contractor's License No.
P 0 BOX 101 CALIMESA, CA 92320 V (909)522-2219
Business Address Telephone No.
P 0 BOX 101 CALIMESA, CA 92320 (909)522-2219
Business Address Telephone No.
OIIO31
City Business License No.
JAMES RIVER INSURANCE COMPANY 000659951
Applicant's Insurance Company Policy Number
Finance Revenue Code
TOTAL: $0.00
PERMIT NO: C1P2016-0003
DATE ISSUED:
EXPIRATION DATE:
BY:A
WORK INSPECTED BY*:
PERMIT COMPLETION DATE*:
*If the work is covered by a Subdivision Improvement Agreement,
Subdivider shall request final acceptance of improvements from the
City Council.
CAr
Purpose of Construction (i.e.: Rough Grading, Mite Street, etc.)
Description of Construction (i.e.: See Plan Set No. 012)
Dimension of Installation or Removal:
Approximate Construction Start Date:
Approximate Construction Completion Date
Estimated Construction Cost:
Estimated Construction Construction Cost shall include the removal of all obstructions, materials, and debris, back-filling, compaction and
placing permanent resurfacing and or.replacing improvements
S
Co' ntact Name: fJS 5Phone Number:.Z2
Name of Applicant/Owner:EE%i4 bCR ' '7.
Applicant Address V ?z (
Applicant Telephone Number I £yc- ?
Applicant E-mail AddressfE 4 to L4..
Name of Contractor:
Contractor Address 1Sitc 1 Z
Contractor Telephone Number
Contractor State License Number 4- I
Contractor City Business License Number: •- •.
Contractor E-mail Address:,'
110- A COPY OF THE CURRENT INSURANCE CERTIFICATE MUST BE PROVIDED
Applicant or Contractor General Liability Insurance Compan
4
Applicant or Contractor General Liability Insurance Policy Number:
Office Use Only: • Office Use Only: •
Inspection Fee: S Assigned P rmit Number: • • S
Permit Fee. • Approval Date:
As-Built Expiration
Deposit: • Date:___________________________________________
Dust Control • • S issue
Deposit: S • • Date:•__________________________________________
Credit
•
• •
•
Amount: • Administrative Authority: •
TOTAL FEE DUE: • • S • •
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