TC2016-0019citt41:, 01' .4, u11a1 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: 2/22/2016
LOCATION OF CONSTRUCTION(Street address or Description): JEFFERSON STAND AVE 52
PURPOSE OF CONSTRUCTION: TRAFFIC CONTROL TO INSTALL ART PIECE PEDESTAL
DESCRIPTION OF CONSTRUCTION: CIP 2015-10 JEFFERSON ROUNDABOUT ART PIECE PEDESTRAL
DIMENSION OF INSTALLATION OR REMOVAL:
TE TIME WHEN WORK WILL BEGIN: 2/25/2016 TIME OF COMPLETION: 3/15/2016
ESTIMATED CONSTRUCTION COST: (Including removal of all obstruction, materials, and debris, backfilling, compaction and placing
permanent resurfacing and/or replacing improvements)
COMMENTS: (SEE CIP2015-10 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
(: urs prior to the anticipated inspection.
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules an4fgula ions of e City of and
to pay for any additional replacement necessary as the result of this work. \ /1
TRI - STAR CONTRACTING II - BRYAN
WILLIS 15 -501 LITTLE MORONGO ROAD DESERT HOT SPRINGS, CA 92240
Name of Applicant (please print) Business Address
TRI - STAR CONTRACTING II INC 15-501 LITTLE MORONGO ROAD DESERT HOT SPRINGS, CA 92240
Name of Contractor and Job Foreman Business Address
Ikanfor Agent
(760)251-5454
Telephone No.
(760)251-5454
Telephone No.
909195 LIC-762
Contractor's License No. City Business License No.
IRONSHORE SPECIALTY INSURANCE CO AGS0003004
Applicant's Insurance Company Policy Number
Finance Revenue Code
TOTAL: $0.00
PERMIT NO: TC2016-0019
DATE ISSUED:
EXPIRATION DATE: 7
BY:
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.
PUBLIC WORKS DEPARTMENT
APPLICATION FOR PERMIT.••
am
Tract No: Name:
Vicinity ED
1 11 Purpose of Construction (i.e.: Rough Grading, Offsite Street, etc:).
Description of Construction (i.e.: -See Plan Set NO. 01234)
Dimension of Installation or Removal L . =
. _
7e
.•. :
Approximate Construction Start Date: :
Approximate Construction Completion Date
.' Estimated Construction Cost $['7cZiT .
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 Number:Q..!Y
Name of Applicant/Owner:
Applicant Address k tE1
Applicant Telephone Number:
.
Applicant E-mail Address:P1 "
.
... _______ ____________
Name of Contractor:LS
. F;•'. Contractor Address:
Contractor Telephone Number:
Contractor State LicenseNumbC
I I