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CIP2017-0005oi 4 ULftt See below for Finance Revenue Codes ENCROACHMENT PERMIT 'OF. 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: 7/25/2017 LOCATION OF CONSTRUCTION(Street address or Description): DESERT CLUB. MONTEZUMA. & WASHINGTON PURPOSE OF CONSTRUCTION: SLURRY AND STREET REHAB DESCRIPTION OF CONSTRUCTION: C1P2012-07E PMP PHASE 2 DESERT CLUB SLURRY & MONTEZUMA REHAB DIMENSION OF INSTALLATION OR REMOVAL: PER APPROVED PLANS AND SPECIFICATIONS APPROXIMATE TIME WHEN WORK WILL BEGIN: 7/31/2017 TIME OF COMPLETION: 10/23/2017 ESTIMATED CONSTRUCTION COST: 5670.000.00 (Including removal of all obstruction, materials, and debris, backfilling, compaction. and placing permanent resurfacing and/or replacing- improvements) SEE PROJECT CONTRACT AND SPECIFICATIONS FOR CIP 2012-07E 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. Signature of Apolicant or Agent ALL AMERICAN ASPHALT - ADRIAN SOTO P 0 BOX 2229 CORONA, CA 92878 (951)736-7600 Name of.Applicant (please print) Business Address Telephone No. ALL AMERICAN ASPHALT P 0 BOX 2229. CORONA, CA 92878 (951)736-7600 Name of Contractor and Job Foreman Business Address Telephone No. 267073 764057 Contractor's License No. City Business License No. ARCH SPECIALTY INS CO . . DPC100585600 Applicant's Insurance Company S Policy Number Finance Revenue Code TOTAL: $0.00 PERMIT NO: C1P2017-0005 DATE ISSUED: EXPIRATI9N DATE: iLk' Is BY: WO'RK INSPECTED BY*: PERMIT COMPLETION DATE*: 51f the work is covered by a Subdivision Improvement Agreement, Subdivider shall request final acceptance of improvements from the City Council. E~Z, NMI= PUBLIC WORKS DEPARTMENT APPLICATION FOR PERMIT Date: Tract No: OI2'1 Project Name: /''1c ,ej R ctItr Vicinity:.,t re Q /oi P.c (./urpoeof Construction (i.e.: Rough Grading, Mite Street, etc.) trrc., ), .. Descriptionof Construction(i.e.:SeePlanSet No. 01234),Sec•(_ R., Dimension of Installation or Removal: Approximate Construction Start Date: ?/t_/1_?_- Approximate Construction Completion Date: I, Estimated Construction Cost: $ (.o7o._Oo. OD Estimated Construction Cost shall include the removalof all obstructions, materials, and debris, back-filling, compaction and placing permanent resurfacing and or replacing improvements Contact Name:. Name of of App1icant/Owier: A Applicant Address: ()._c _R-1 , Applicant Telephone Number: Applicant E-mail Address: ri sc o Name of Contractor: 1-4_1_I—rvtr._C. Contractor Address: (? o,a , Contractor Telephone Number: ( 53 1) Contractor State License Number: Contractor City Business License Number: Contractor E-mail Address: I, L - i Ii Phone Number: JA L1L c 'or )bLO57 r ccl1Ct*. A COPY OF THE CURRENT INSURANCE CERTIFICATE MUST BE PROVIDED-4 Applicant or Contractor General Liability Insurance Company: Applicant or Contractor General Liability Insurance Policy Number: C f Office Use Only: Inspection Fee: Permit Fee: As-Built Deposit: Dust Control Deposit: Credit Amount: TOTAL FE DUE:co Office Use Only: Assigned permit Number (( ZL7 000 Approval Date: Expiration Date:____________________________________________ issue Date: Administrative Authority: ication fo