TC2016-0033See below for Finance Revenue Codes
ENCROACHMENT PERMIT
t0p T%
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: 5/16/2016
LOCATION OF CONSTRUCTION (Street address or Description): MADISON ST FROM AIRPORT BLVD TO AVE 54
PURPOSE OF CONSTRUCTION: TURF REMOVAL AND ENHANCEMENT OF MEDIAN
DESCRIPTION OF CONSTRUCTION: CIP 2015-04 MADISON ST MEDIAN LANDSCAPE CONVERSION IMPROV
DIMENSION OF INSTALLATION OR REMOVAL:
APPROXIMATE TIME WHEN WORK WILL BEGIN: 6/1/2016 TIME OF COMPLETION: 8/31/2016
ESTIMATED CONSTRUCTION COST: S500.000.00 (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 CIP 2015-04 FOR PERMIT CONDITIONS 7
- - /
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 re u i ns of City of and
to pay for any additional replacement necessary as the result of this work.
2.
Signature of Appli nt or Agent
URBAN HABITAT ENVIRONMENTAL
LANDSCAPES P0 BOX 1177 LA QUINTA, CA 92247 (760)296-3603
Name of Applicant (please print) Business Address
. Telephone No.
URBAN HABITAT ENVIRONMENTAL S
LANDSCAPES P0 BOX 1177 LA QUINTA, CA 92247 . (760)296-3603
Name of Contractor and Job Foreman Business Address Telephone No.
963744 LIC-0004501
Contractor's License No. City Business License No.
TRUCK INSURANCE EXCHANGE 60477-75-72
Applicant's Insurance Company . Policy Number
Finance Revenue Code
TOTAL: $0.00
PERMIT NO: TC2,016-0033
DATE ISSUED: 01
EXPIRATION DATE: e efll -7
BY:
WORK INSPECTED BY*:
IPERMIT 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 FORPERMIT
Date: L- t"n/eVOn
Tract No: iect Name:
Vicinitv:
Purpose of Construction (i.e.: Rough Grading, Offsite Street; etc.)flffi)IY 1
:
De cri lion of C s tion •.e.: See Plan Set No. 01234) _______________
• : .. .' z.4 '. •4 ••'S•• Dimension of Installation or Removal
: . s4
Approximate Construction Start Date: U
Approximate Construction Completion Date 1A USiA
Estimated Construction Cost $LSO7OO t
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 t1eYL&)Ifl - Number
Name of Applicant Ii 6tiiri 97
Applicant Address I r '..31 R113~2 71_U c
Applicant Telephone Number '
; I
Applicant E-mail A
Name of Contractor: _________________________
Contractor Address F I (Ti u j.
Contractor Telephone Number:
Contractor State License Number:
Contractor. City Business License Number: F
Contractor E-mail Address:.,:e t tUV f itL&ki
A COPY OF THE CURRENT INSURANCE CERTIFICATE MUST BE PROVIDED
Office-Use Only:
C_ (
Inspection Fee:
Permit Fee:
As- Built
—
Dust Control
Deposit:
Credit •
• • Amount:
TOTAL FEE DUE:
Urive/ufleckllsts - 1-orms & #kppllcatlol
Office Use Only:
Assigned Permit Number: '7Z.Q ji, "oo
Approval Date:
Expiration
Date: •
Issue
Date:
Administrative Authority: :
'inlirntinn few I.'ewmit nnrrui R7, R-1 ig