DRVA2017-0008TIJ 7jj7 -DOD?
DRIVEWAY APPROACH PERMIT APPLICATION
Applicant Information:
Applicant/Owner (please p!Jt name here) Alm 't - b4
Applicant Address: 71 #J#P,4 *iiq L /j1c*
Number Street City State Zip Code
Address or Parcel No. of work location, if different from applicant's address above:
Number Street - City State Zip Code
Date: i2j1 Applic t's Phone No (144 .17L) 1ZZ6'
Applicant's Signature: -,
Approximate Start Date: Z./J/I7 Approximate Completion Date: 2i',l7
Contractor lnformatlbn:
Addess: i *Rv C14 1717~ 10 3
Number Street City State Zip Code
Phone Number: (740 $ I Contractors License Number:
City Business License Number: ______
General Liability. Insurance Corn Policy 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. The Hub Counter (760) 777-7125.
Please Note.-.Inspections are normally performed Monday through Friday between 8am and 4pm
Permit Fee $152 + $5 Technology Enhancement Fee = $157 Total Fee
Permit No. Date
Permit Issued by: Date Issued
Signature of Administrative Authority
Work Inspected by: Permit Completion Date: _l_I
Inspector's Signature
Comments:
Note: Driveway approach must be constructed per City of La Quinta Standard #221
a,.—.
MRDEVEL.01 DNIELSE ARI.I
CERTIFICATE OF LIABILITY INSURANCE
OATE(MMIODNYYY)
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
BELOW. 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 pollcy(Ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). ... ... -
PRODUCER License # 0F09643 .gcT Diane-Nielsen
Desirt empire Ins Services,
Inc.
7-7.564l'totintry Club Drive c; o .IfxI 7601 360-4700 t.No):(76O) 200.9706
Suite 401 S. dIano.niolsen@desedemPIreins.com -
Palm Desert, CA 92211 O1SURER(S)f9RDINO COVERAGE
,NsuRERA.Mesa Underwriters Specialty ins Co 3.8..38
INSURED !B Benchmark Insurance Company 41394_____
M. R. Development Inc. INSURER C: DBA: A 8 M Construction
P 0 Box 366
La Qulnta, CA 92247 IM
- INSURERFg
1DA1O — - rDTIIaAY P.11 IMD. -- - - D%IIGIAM MIIMcD
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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, i
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR LTR TYPE OF INSURANCE
- gp AODL15UBR POUCY NUMBER POLICY EFF IMMIDD1YYYY POLICY EXP
jIyyyyL UMITS________________
A X I COMMERCIAL GENERAL. LIABILITY
CLAIMS.MADE[J OCCUR
& Contractor
JJ
xf
Owner's
_. -
MP0104014000035
FGENt AGGREGATE LIMIT APPLIES PER:EN
1210112016 1210112017.
.
EACHocçuRRENE_
DAMAGE TO RENTED
MED EXP_(yppetsc)
$ 1,000,000
$ 100,000
-5,000
PERSONAL &ADV INJURY 8 1,000,000
_________________________ POUCY [j] LOC
IgThER:
GERLGGREGATE...$
f5DUCTSOMPIOPAGO
.2,000,000
$2,000,000
• AUTOMOBILE LIABILITY
ANY AUTO
SCHEDULED
AUTOS ONLY AUTOS
- OWNED
H-L
" M?SONLY O %Ntj~
- - .
S
g8
.
COMBINED SINGLE LIMIT
BODILY INJURY (pera
BOOILYINJURY (Per accident)
s -
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS-MADE
DED I_IRETENTION$
EACH OCCURRENCE__
AGGREGA
$______________
$______________
—
B
-
WORKERS COMPENSATION
AND EMPLOYERS LIABILITY - YIN
ANY PROPRIETOR/PARTNERIEXECUTIVE J EXCLUDED?
Uyu.descilbeuncier
DESCRIPTION OF OPERATIONS below
NI A
_
CST5009321
I •
. '- - -. - . •--•
0110112017
-
0110112018
- -
PER _....LsrEJ___LR_..
EEACHçjDENT 1,000,000
-- . E.L DISEASE.. POLICY LSST
$_1,000,000
5.- 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101 Additional R.m.rk. Schedule, ,nay ho ettachsd I? mwoapac.I, r.qulr.d)
Coral Option I, LLC, Coral Option I, LLC dlb(a Andalusia ãountry Club, TD Desert DevoIopmet Corporation and Pyramids Joint Venture, LLC are named as
additional Insured per attached MUS 01 0`120128 0316. Insurance Is primary and non- contributory.
30 days written notice will be given to the certificate holder should any of the above policies be cancelled before the expiration date. 10 days notice applies for
non payment of premium.
ACORD 26 (2016/03) - .• .. -. •• ID 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD