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