PG2015-000701'
S See below for Finance Revenue Codes
" ENCROACHMENT PERMIT
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: 8/25/2015
LOCATION OF CONSTRUCTION(5treet address or Description): AVENUE 50 AND PARK AVE
PURPOSE OF CONSTRUCTION: CIP 2014-01B PHASE 2; REMOVE AND REPLACE CONCRETE SIDE
DESCRIPTION OF CONSTRUCTION: CIP 2014-01B PHASE 2; LA QUINTA SPORTS COMPLEX MISC. ADA IMP
DIMENSION OF INSTALLATION OR REMOVAL:APPROX. 7.000 SF
APPROXIMATE TIME WHEN WORK WILL BEGIN:8/25/2015 TIME OF COMPLETION: 9/25/2015
ESTIMATED CONSTRUCTION COST:S115.000.00 (Including removal of all obstruction, materials, and debris, backfilling, compaction and
placing permanent resurfacing and/or replacing improvements)
COMMENTS: SEE PROJECT CONTRACT AND SPECIFICATIONS 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 Applicant or Agent
RALPH GONZALEZ 33562 VUCAIPA BLVD, SUITE 4-13 YUCAIPA, CA 92399 (909)904-5112
Name of Applicant (please print) Business Address Telephone No.
R G GENERAL ENGINEERING 33562 YUCAIPA BLVD STE 4-132 YUCAIPA, CA 92399 (909)904-5112
Name of Contractor and Job Foreman Business Address Telephone No.
978079
Contractor's License No.
MESA UNDERWRITERS SPECIALTY INSURANCE
Applicant's Insurance Company
Finance Revenue Code
TOTAL: $0.00
LIC-763023
City Business License No.
MP0004008003040
Policy Number
-
PERMIT NO: PG2015-0007
DATE ISSUED:
EXPIRATION DATE:4t
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.
Date:
ilçpo' VED
PUBLIC WORKS DEPARTMENT !Ii2oi5
APPLICATION FOR P
Project Name: -
frTh?4. 0o
wi t
Lo -1)1 13 EN
Tract No:
Vicinity:
Purpose of Construction (i.e.: Rough Grading, Mite Street, etc.)2tac. 4
ChvV!. $11U( .i iVi 1C1fE.fE
.
40 077/mr. •rEM
Description of Construction (i.e.: See Plan Set No. 01234) #&c,-MLA.CC,1 ,iujIk,
, er oEci' t)D. 2bI —018
Dimension of Installation or Removal: '4i4'O.øi 'l,OOô
Approximate Construction Start Date: 8111 ( is-
Approximate Construction Completion Date: i f-V, / sf
Estimated Construction Cost: $ 1(5 DO(.)
Estimated Construction Cost shall include the removal of all obstructions, materials, and debris, back-filling, compaction and
placing permanent resurfacing and or replacing improvements
Contact Name: JtØfII Cro 7A1.Et. Phone Number: cfbg 90
Name of Applicant/Owner: 1VLJH EoI7AL.Z.
Applicant Address: 33 s62. 16c&FA isob.5wTV 4p/32 1 c14l?A C/I qZ3fl
Applicant Telephone Number: b1 q#j _g,,
Applicant E-mail Address: renefti(efl mail. cb,vl
Name of Contractor:
Contractor Address: 5?L J&cmm pi..vr' 11I3L • 'i?iie4IQA C,1 CiZ399
Contractor Telephone Number: g7 9' - SWI
Contractor State License Number: g i
Contractor City Business License Number: 7(63O2
Contractor E-mail Address: ',aJj cn
A COPY OF THE CURRENT INSURANCE CERTIFICATE MUST BE PRO VIDED 4
Applicant or Contractor General Liability Insurance Company:
ME5A uND. l4MZ411S 5&Mi-rV ,)(-'
Applicant or Contractor General Liability Insurance Policy Number:
9P&eo4 0019003040
Office Use Only: Office Use Only:
Inspection Fee: Assigned Permit Number: (,ZJ) IS''- cI00"7
Permit Fee:
As-Built
Deposit:
Dust Control
Deposit:
Credit
Amount:
TOTAL FEE DUE:
Approval Date:
Expiration
Date:
Issue
Date:
Administrative Authority: