CIP2018-0002Qa~tr See below for Finance Revenue Codes
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CIP
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: 7/12/2018
LOCATION OF CONSTRU CTION (Street address or Description): ADAMS ST AND BLACKHAWK WAY
PURPOSE OF CONSTRUCTION: ADA IMPROVEMENTS.: SEE APPROVED PLANS
DESCRIPTION OF CONSTRUCTION: CIP 2017-05 LAQI,JINTA SCHOOL ADA IMPROVEMENTS
DIMENSION OF INSTALLATION OR REMOVAL:
APPROXIMATE TIME WHEN WORK WILL BEGIN: 7/23/2018 TIME OF COMPLETION: 8/31/2018
ESTIMATED CONSTRUCTION COST: S180.799.00 (Including removal of all obstruction, materials, and debris, backfilling, compaction and
placing permanent resurfacing and/or replacing improvements)
MMENTS: SEE PROJECT CONTRACT AND SPECIFICATIONS FOR CIP 2017-05 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.
4inature of Applicant or Agent
TRI - STAR CONTRACTING II INC - TED
KREHBIEL 15501 LITTLE MORONGO ROAD DESERT HOT SPRINGS, CA 92240 (760)251-5454
Name of Applicant (please print) Business Address Telephone No.
TRI - STAR CONTRACTING II INC 15501 LITTLE MORONGO ROAD DESERT HOT SPRINGS, CA 92240 (760)251-5454
Name of Contractor and Job Foreman Business Address Telephone No.
909195 LIC-0000762
Contractor's License No. City Business License No.
UNITED SPECIALTY INSURANCE COMPANY ATN-5F1822041
Applicant's Insurance Company Policy Number
Finance Revenue Code
TOTAL: $0.00
PERMIT NO: C1P2018-0002
DATE ISSUED: -1 11% /t
EXP IRA TI9N DATE: (% 1 '
BY.
WQI(K INSPECTED BY*:
I PERMIT COMPLETION DATE*:
*If the work is covered by a Subdivision Improvement Agreement,
Subdivider shall request final acceptance of improvements from the
City Council.
4a"
e.: See Plan Set No. 01234
Dimension of Installation or Removal:
Approximate Construction Start Date:
Approximate Construction Completion Date:
Estimated Construction Cost:
Estimated Construction Cost shall include the removal of all obstructions, materials, and debris, back-filling, compaction and
placing permanent rcsirfacing and or replacing improvements
S S S • S ?*-A M 'illI i;
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We SI! Sa II h*$
10- A COPY OF THE CURRENT INSURANCE CERTIFICATE MUST BE PROVIDED 4
)olicant or Contractor General Liability Insurance Comnanv:
licant or Contractor General ility Insurance Policy Number:
Office Use Only:
Inspection Fee: -
Permit Fee:
As-Built
Deposit: -
Dust Control
Deposit:
Credit
Amount:
TOTAL FEE DUE:
lication
Office Use Only:
Assigned Permit Number:
Aporoval Date:
Expiration
Date:
Issue
Date:
Administrative Authority: