CIP2016-0006See below for Finance Revenue Codes
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.
DATE: 11/22/2016
LOCATION OF CONSTRUCTION(Street address or Description): CALLE TECATE & AVENIDA MADERO
PURPOSE OF CONSTRUCTION: LANDSCAPING
DESCRIPTION OF CONSTRUCTION: CIP 2015-11 COVE OASIS TRAILHEAD IMPROVEMENTS
DIMENSION OF INSTALLATION OR REMOVAL: SEE APPROVED PLANS
APPROXIMATE TIME WHEN WORK WILL BEGIN: 12/5/2016 TIME OF COMPLETION: 1/20/2017
ESTIMATED CONSTRUCTION COST: S85000.00 (Including removal of all obstruction, materials, and debris, backfilling, compaction and
placing permanent resurfacing and/or replacing improvements)
COMMENTS: SEE PROJECT CONTRACT AND SPECIFICATIONS FOR CIP 2015-11 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 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) 777-7097. 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 applicable rules and regulations of the City of and
to pay for any additional replacement necessary as the result of this work.
tgnature fçpIicai! or Agent
CALIFORNIA SKATEPARKS - MARIO
RODRIGUEZ 273 NORTH BENSON AVENUE UPLAND, CA 91786
Name of Applicant (please print) Business Address
CALIFORNIA SKATEPARKS 273 NORTH BENSON AVENUE UPLAND, CA 91786
Name of Contractor and Job Foreman Business Address
(909)949-1601
Telephone No.
(909)949-1601
Telephone No.
962150
Contractor's License No.
MAMUM INDEMNITY CO.
Applicant's Insurance Company
Finance Revenue Code
TOTAL: $0.00
LIC-764306
City Business License No.
G1P6018445-05
Policy Number
PERMIT NO: C1P2016-0006
DATE ISSUED:
EXPIRATION DATE: J- /1
BY:
WQI('I 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.
T/df 44 abdL
PUBLIC WORKS DEPARTMENT
APPLICATION FOR PERMIT 7
Date:
TractNo:C11 eøectNarne:Cc e Trc~Aqd 1i..
Vicinity: a P Z 0 ( II
Purpose of Construction (i.e.: Rough Grading, Offsite Street, etc.)
Description of Construction (i.e.: See Plan Set No. 01234) 9 fYOVe 1&1t?s
Dimension of Installation or Removl: See A-ft'rovecl P
Approximate Construction Start Date: es- - S - 2.0
Approximate Construction Completion Date: )c.v\ 2_b - 1 1
Estimated Construction Cost: $ 5 0 c.o
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:. R c i Phone Number:
Name of Applicant/Owner: C ctAi a-5
Applicant Address: 273 txI e.vts c' A' e- 00 1" C. i- g I 1 c6
Applicant Telephone Number: g oci A J-L 'l 16 O I
Applicant E-mail Address: vcrp a c L Ictk4flc3
Name of Contractor: ~Se M
Contractor Address:
Contractor Telephone Number:
Contractor State License Number: 1 6 2-1 5 O
Contractor City Business License Number: 7 & o
Contractor E-mail Address:
A COPY OF THE CURRENT INSURANCE CERTIFICATE MUST BE PROVIDED .4
Applicant or Contractor General Liability Insurance Company:
Applicant or Contractcneral Liability Insuffi!(ce Policy Number:
G-LP ot
1L1S 0c
Office Use Only:
Inspection Fee:
Permit Fee:
YQ' As-Built
Deposit:________________________________________
Dust Control
Deposit:
Credit
Amount:
TOTAL FEE DUE: 0
i I iriuPll :hIt I-rrme .W. Annhir1irir phcation fo
Office Use Only:
Assigned Permit N umber:C,I ('Zoi &-O3b
Approval Date:
Expiration
Date:
Issue
Date:
Administrative Authority: