DRVA2016-001010
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ENCROACHMENT PERMIT
PUBLIC WORKS CONSTRUCTION
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For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewe 5, water rr rid IVfke Oubli,
PA works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS. COMMUNIIYDEVELOPMENTDE 1! IZI
DATE: 8/16/2016
LOCATION OF CONSTRUCTION(Street address or Description): 51325 EISENHOWER
PURPOSE OF CONSTRUCTION: DRIVEWAY APPROACH PER CITY STANDARD 221
DESCRIPTION OF CONSTRUCTION: ROZ BUILDERS / DRIVEWAY APPROACH
DIMENSION OF INSTALLATION OR REMOVAL:
APPROXIMATE TIME WHEN WORK WILL BEGIN: 8/16/2016 TIME OF COMPLETION: 8/21/2016
ESTIMATED CONSTRUCTION COST: (Including removal of all obstruction, materials, and debris, backfilling, compaction and placing
permanent resurfacing and/or replacing improvements) S
COMMENTS:
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 Applicant or Agent
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ROZ BUILDERS
Name of Applicant (please print)
ROZ BUILDERS
Name of Contractor and Job Foreman
972979
31305 LAS FLORES WAY THOUSAND PALMS, CA 92276 (760)674-6559
Business Address Telephone No.
31305 LAS FLORES WAY THOUSAND PALMS, CA 92276 (760)674-6559 -----------------
Business Address Telephone No.
LIC-762975
Contractor's License No.
UNITED SPECIALTY INSURANCE COMPANY
Applicant's Insurance Company
Finance Revenue Code
PERMIT INSPECTION
DRIVEWAY RESIDENTIAL S $145.00
TOTAL: $145.00
City Business License No.
51105031318477
Policy Number
PERMIT NO: DRVA20I6-0010
DATE ISSUED: LO(o
EXPIRATION DATE:
BY: 06/
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.
'FY DRIVEWAY APPROACH PERMIT APPLICATION
Finance Revenue Code PD
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Applicant Information:
Applicant/Owner (please pjJjt name here): 0 7..
Applicant Address: Si 2..5 e..i 1-c#.- Qvjryn c. c?2.7.3q
Number Street City State Zip Code
Address orParcel No. of work location, if different from applicant's address above:
Number Street City State Zip Code
Date: rfi/P Applicant's Phone No: 0)(.Ø7 (PJ
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Applicant's Signature: c7 -----'
Approximate Start Date: it('i* Apfroximate Completion Date:
Contractor Information:
Address: 31 3 0 -5 tc-& fofe5 Wa. Tko#c( jli fr 2Z7t
Number Street City State Zip Code
Phone Number: (iI ølContractors License Number: ? 72-' 1
City Business License Number:
General Liability Insurance Company:OAhPolicy No.
Request for Inspection - Please call (760) 777-7097 before 1:30pm to request an inspection at least 24
hours prior to your requested inspection date. Public Works Counter (760) 777-7075.
Please Note: Inspections are normally performed Monday through Friday between 8am and 4pm
Permit Fee $145 = $145 Total Fee
Permit Nol .Uc2ot.-cDeOExpiration Date ' /I
Permit Issued by: Date Issued I /
Signature of Administrative Authority
Work Inspected by: Permit Completion Date: //
Inspector's Signature
Comments:
Note: Driveway approach must be constructed per City of La Quinta Standard #221