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DRVA2015-0017gtha" See below for Finance Revenue Codes o.j!' 114z1 % ENCROACHMENT PERMIT or, 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: 9/11/2015 LOCATION OF CONSTRUCTION(Street address or Description): 54925 AVENIDA RAM IREZ PURPOSE OF CONSTRUCTION: DRIVEWAY APPROACH DESCRIPTION OF CONSTRUCTION: DRIVEWAY APPROACH DIMENSION OF INSTALLATION OR REMOVAL:N/A MATE TIME WHEN WORK WILL BEGIN: 9/15/2015 TIME OF COMPLETION: 9/18/2015 ESTIMATED CONSTRUCTION COST:S3M00.00 (Including removal of all obstruction, materials, and debris, backfilling, compaction and placing permanent resurfacing and/or replacing improvements) Inconsideration 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(7)277-7097. 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. *naturepplicant or PETER AND SHELIA COMPTON 16461 QUANTICO ROAD APPLE VALLEY, CA 92307 Name of Applicant (please print) Business Address BAJA CONCRETE 52435 EISENHOWER DR LA QUINTA CA 92253 Name of Contractor and Job Foreman Business Address 964123 LIC-0099706 Contractor's License No. City Business License No. (408)483-3355 Telephone No. (760)296-3368 Telephone No.. US SPECIALTY INSURANCE CO. Applicant's Insurance Company Finance Revenue Code PERMIT INSPECTION DRIVEWAY RESIDENTIAL $145.00 TOTAL: $145.00 U15A81103-01 Policy Number PERMIT NO: DRVA2015-0017 DATE ISSUED2/4-s- EXPIMTIOV D4//49 WORK INSPECTED BY*: PERMIT COMPLETION DATES: 51f the work is covered by a Subdivision Improvement Agreement, Subdivider shall request final acceptance of improvements from the City Council. PUBLIC WORKS DEPARTMENT QUIJ APPLICATION FOR PERMIT Tract No: 'Project Name: $'/42 iien,da.. Rc'in;re2 - -.. Vicinity: L ' ic ' Cøir— AM 29 3O2.) fl .ii t)) Purpose of Construction (i.e. :"Rough Grading, Offsite Street, etc.)3 iobvi Description of Construction (i.e.: See Plan Set No. 01234) _______ TYcb .iciiJ6 rU.. 3 kJEW 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 resurfacing and or replacing improvements I Contact Name: VIt COitVfIyJ Phon Number: 19 Lf) 339:s- I Name of Applicant/Owner: Cg1'313r3 I I Applicant Address: Applicant Telephone Number: l+3 -33sc I Applicant E-mail Address: Name of Contractor: S9".) P' ceHU*1 Contractor Address: Contractor Telephone Nuier: ? 60 246 3 oe I Contractor State License Number: Contractor City Business License Number: Contractor E-mail Address: A COPY OF THE CURRENT INSURANCE CERTIFICATE MUST BE PROVIDED -4 Applicant or Contractor General Liai1ity Insurance Company: Ofl' dwsgj 5OCO&RJ ttc- J(\f, Applicant or Contractor General Liability Insurance Policy Number: Office Use Only: Inspection Fee: Pcrtpit Fee: As-Built Deposit: Dust Control Deposit: Credit Amount:. TOTAL FEE DUE: I urive/eneckllsts - Forms & ADDlIc[lonsAOlIiCatiofl Office Use Only: Assigned Permit Number: Approval Date: Expiration Date: Issue Date: Administrative Authority: BAJAC-1 OP ID: AC CERTIFICATE OF LIABILITY INSURANCE DATE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES oa..ow. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER IMPORTANT; If the certificate holder Is an ADDITIONAL INSURED, the pallcy(tes) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may inquire an endorsement A statement on this certificate does not confer ilgtes to the certificate holder In lieu of such endorsement(s). inocucce Ow and Associates Ins. Set,. CALICOESS493 P11(959508.5859 28780 SIngle Oak Drive 9255 Ternecula, CA 92590 CONTACr UNM PHONE FAX iic. 'rob E.OAA. weunnqe Amoccvm KAICS NeUUulIA:U.S. Specialty Insurance Co. 28599 INSURED B* Concrete 52435 Eisenhower Dr. La Quinta. CA 92253 CAUFORNIA AUTO INSURANCE CO 38342 erwnernc-EVEREST NATIONAL INS CO 10120 INSURER E: 1NSlF; IcernrIrAT unuoco REVISION NUMRER This IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR 07HM DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTIR ivre or DIBIRANcE POLICY mjuem III LAM A OBIreALUABEiTY i coucacu,i. capeino.uaiuw I CI.AIMS.MADE [] OCCUR X X - 115AC8110301 ___________ 0212312015 ____ 0212312016 ____ EACHOCCURKNCE $ 11000,OJJl $ 100,001 (Myeispeew)) $ PER ____ 5101111 ______ SCNAL&AOVIt4AJRY $ 1,000,001 GENERAL AGGREGATE $ - 2,000,001 GENt AGG ATE LIMIT APPUES pm POLICY F-1 JEar fl LOC pnooijcs-co.plopoc $ 2,000,001 - B MITO500ILELIA01UTV MIY AUTO ALL AUTOS - NoroMan - H1REDAUTOS AUTOS 1A040000019259 1211312014 121312015 aT 300,08 BOSILY itPpcn) $__________ BCOLYRIJUf(Predt) $ PROPURTY DAMAGE FOR $ - uuamaa.AUAB HCLASIG-41ADE oco.m - . ______ EACHOCDJINCE AGOREGATE $ - cod IREtENTlONS _____________ $ - — clum%s CONPeiISARON oecenaan EXCLUDED? LI -SilaiNN) o eurnos - r600910LOVERS' LIABILITY Yin ó12543151 M IA - - . 0311012015 0311012015 _________ x 1TJ[ I Ej. EACH ACCIDENT 5 1.000,08 EL SEASE-EABIPLOYE $ 1,000,001 E.L. OISEASE- POLICY UNIT $ 1,000,08 oEscnoN or OPERM1CNSSLCCATIONSIVAICUS (A. *eooc 101. A,.i 5thrdu?, emas b.iquk) RTIFICATI HOLDER IS RMIHD AS ADDITIONAL Insw LUl FID CANnFLLATInM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED B0BE THE EXPIRATION bAit THEREOF. NOTICE WILL BE DELIVERED IN CITY OF LA QUINTA ACCORDANCE WITH THE POLICY PROVISIONS. 784185 CALLE TAMPICO ABThOV,ffA1WE LA auiNTA, CA 92253 ID 1B88.01U AURU GUNPURR11UN. All R9I1W roaervea. ACORD 25 (2010105) The ACORD name and logo are registered mania of ACORD P01 ICY N(JMF: tJ1 SAM 1fl-fl1 COMMERCIAL GENERAL LIABILITY wrs min nc 4n1 - THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. U&IAV AM MM( HTV AM U U • UU U U U U_2 U %.SU - W..J_U - U U US_a S..1 U S_a. U S U_S S_a S__U - U U WAIVFR OF SIIRROC-ATIflN This endorsement modifies insurance provided under the following: nra •i IVfl#I Al n,s,,r, Al. I I A flu ,r, r%rsl VIfi A n, flA flV• '..e'.JIVIIVII_I .eIIL 'uI_IfL I..irijui_i.i I V I_I %lJl_ I ri S I PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A.. PRIMARY AND NON-CONTRIBUTORY TO I'HII INMUWAN(:e- IVI4.I-------£ £_. ........................LL_ :_ V VIII II (U 0117 1JGI 01.111 UI UI Ql IlLOIlUl I II lOt 10 an additional insured under this Coverage Part, the following is added to paragraph 4. of aea,.asl IVI SflUUSSIfll SI M IL %.%JIVIIVII_T%%IPiL I_.lSI.fS?SL. II JiWI I If you have agreed in writing in a contract or agreement that this insurance is primary and non- contributory relative to an additional insured's own I,IsullIL,LIII iisuisu.uit uSiJ,IIti,V. a,iu' w will not -seek contribution from- that other, insurance. For the purpose of this endorsement, the additional insured's own insurance means insurance on which the additional insured is a Named insured. %AII.... el.,;. ;._ &.. Ak.. ....l;..,. A II S%1 I se,,a,,Ia%,,.aI.., 111.11k 1.1 S&fll.4%#I $1.14 111 II 1 JL#ll%i_7 IL supersedes all other insurance conditions within. B. WAIVER OF sUOGROGRATIoN - BLANKET Ill IUI UIV.V I ISIS IV - ISISIlIlUIIlISIVS ISI..ISA..ISI IS_I, 1Vt na.u,.,rin.Ia Th e .__ _t__ . L..IISIIl.l I ISISISI I Il.#ISI I I 10 I I ll0IOI ISI Rights Of Recovery Against Others To Us Condition. is amended by the addition, of the II4IIIlVVII lU We waive any right of .recovery we may have against any person or organization because of payments we make for injury or damage arising out of: o. 'our work- incivaèa in the products- completed operations hazard". However, this waiver applies only when you have. nrepr inwritinn in wivpsi,rth rinhis of rprnvpry in n r.nntrct or eernent. And only if tIw contrAct or agreement: Is in. effect or becomes effective during. the -- ...... M1111 LII MAN III IlII.V. I'll Iii Waexecütedprioftolóss HCS 040 0610 13 Paae I of I Includes coPyilAhted material of Insurance Servlces'Office, Inc., wIthltpenisIon. POLICY NUMBER: UI5ACRII03-01 COMMERCIAL GENERAL LIABILITY CG.20 100704 ?LiI CkI7 LhAM#' ILiC rSI 11~i CAC CAI IV ICCIII V U U •U U U Iff-IL11111160 It 111- I U . I &DPI U 41@ I ADDITi:ONAL.INS.U.RED._. OWNERS, LESSEES OR - .Pti U - .0 U •U •U •. -S • -i ( !l%W i,i- .IiJ! I%II: W- - • - • • — • — • • .: a — — — — — — a . • . - - ORGAN iZATiOk I III I.IIIIIU?I.lIIIIII IIIIIII,uII... III?..IIU;lIII:U- IIIIVIIIItII IUIlIII.I IIII IlIUllIWIlIlI .4 COMMERCIAL GENERAL tIABiLITY COVERAGE PART SCHEDULE '.S a:eL......, II .. S aS11 uS II ale -- S SI USS I.a9. OrOrganization(s); Location(s) Of Covered Operation A1110 s Irft,aIIl Ill tIIIirfllUrIllliIl liii Willilil 111111 .1Illilil list IlllIits UIdL oilS uuiiiiy üie puücy piiou wilem you. aiid suii person .or.organiaiion.iiave agreed in'wrhingina.coniracL or agreement that such person or organization be added as an additional insured- oñ your policy. I 1.3.... ....e:...... ..,.. .;......1 a... I...e... el.:... C5 ..L...4. .1... :; -.... ._I..... ._. .:ll I._. ...i......... :.. ci.. III .411 lljlfljfl S Lfl.41415 5.54 •.4I.IS I IUJSL#1 tllt%J5.,SI544JtJS54. II I 545 .411541111 5.45154V.. WSSI 51.4 535154151 III U IS 1.#511.IIt4S 14115.11151. A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or flrr,Jns7*+;rlr,tc rn +hsi QpharhIo hs.# rsrlius ..... .....0-S ,..:ei.. ......f '4, •i S r r ' ,Ien,efla" fly "narenn& 'en?1 'e?1a,4r,nn ink in," ............................ caused, In whole or In part, by: 1. Your acts or omissions; or ' I hP qrtqnrnmissinnq ni ?hnc.4riinn nn Yn,w.. hahilf: in the performance of your ongoing operations for the additional insured(s) at the location (s) desig- lniels I SIIJIJV?1. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- c;,,nc 'enrsler -rrJ i nis insurance aoes not appiy to 000iiy injury or propery damag& occurring aner 1. All work, including materials, parts or equip- ment furnished in connection with such work. nn?hp. nrniPrt rnme.r than se.rvir muntnnr. or rnirs) to he performed 1w or on heheif of the additional insured(s) at the location of the covered operations has been completed; or £. T;.,;. 11111 115111 III Viltil VYIJIft tills Ill VVIIIS.IU 11111 ilIjUly UI uSlI$dye dIibb 110b ueeui JJUL LU Rb III LeIIUU UbUy duuy.pelbul.ul UldIIiLdUUII UUIe than another contractor or subcontractor en- gaged in performing operations for a principal .IS .1 UI.I,; Ill UUl .41111.4 lIIlIIIIi ••- - CG 20 10 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 0