CIP2017-0001al'
tdd See 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: 2/7/2017
LOCATION OF CONSTRUCTION(Street address or Description): 78495 CALLE TAMPICO
PURPOSE OF CONSTRUCTION: ADA IMPROVEMENTS UPGRADE
DESCRIPTION OF CONSTRUCTION: C1P2016-OSA CITY HALL EXTERIOR ADA IMPROVEMENTS
DIMENSION OF INSTALLATION OR REMOVAL: PER APPROVED PLANS
APPROXIMATE TIME WHEN WORK WILL BEGIN: 2/15/2017 TIME OF COMPLETION: 3/21/2017
ESTIMATED CONSTRUCTION COST: $96,332.00 (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 2016-05A 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
to pay for any additional replacement necessary as the result of this work. .10
THREE PEAKS CORP- ERIK SIMMONS P 0 BOX 101 CALIMESA, CA 92320
Wan,~
nc e City of and
of Ap icant or Agent
Name of Applicant (please print)* Business Address Telephone No.
THREE PEAKS CORP P 0 BOX 101 CALIMESA, CA 92320 (909)522-2219
Name of Contractor and Job Foreman Business Address Telephone No.
941528 0111037
Contractor's License No. City Business License No.
JAMES RIVER INSURANCE COMPANY 000659951 4b
Applicant's Insurance Company Policy Number
Finance Revenue Code
TOTAL: $0.00
PERMIT NO: C1P2017-0001
DATE ISSUED:
EXPITION DATE:
BY:,<5.
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.
..
Titf 4 4 a"
PUBLIC WORKS DEPARTMENT
APPLICATION FOR PERMIT
Date:
F ractNo:
icinity
Name:
Purpose of Construction (i.e.: Rough Grading, Offsite Street,
Description of Construction (i.e.: See Plan Set No. 01234
ii
or Removal:
Approximate Construction Start Date: ES7 P
Approximate Construction Completion Date:
Estimated Construction Cost: $ .
Estimated Construction Coat shall include the removal of all obstructions, materials, and debug, back-filling, compaction and
placing permanent resurfacing and or replacing improvements
Contact Name: '
. _Rhone Number:
Name of Applicant/Owner "i
Applicant Address
Applicant Telephone Number:
Applicant E-mail
Name of Contractor:
Contractor Address .
Contractor Telephone Number-
Contractor State License Number
Contractor City Business License Number:
Contractor E-mail
PA COPY OF THE CURRENT INSURANCE CERTIFICATE MUST BE PROVIDED 4
plicant or Contractor General Liability Insurance Comnanv:
icant or Contractor General Insurance Policy Number:
Office Use Only:
Inspection Fee:
Permit Fee:
As-Built
Deposit:
Dust Control
Deposit:
Credit
Amount:
TOTAL FEE DUE:
Office Use Only:
Assigned Permit NUmbcrC I P20 r7-0o o
Approval Date:
Expiration
issue
Date:
Administrative Authority: