0008NOTE: 0 0
With proper validation
this form constitutes an CITY OF LA QUINTA
encroachment permit
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
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
Subdivision Improvement Permit — Class III
DATE:—me.7t�� 198' Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 47"225 Washingtm Street, La Quinta, CA 92253
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION InT OR7L° Mt:S " Per Plan Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION Per Plan
DIMENSION OF INSTALLATION OR REMOVAL Per Plan
SIZE OF EXCAVATION, IF NEEDED Per Plan
APPROXIMATE TIME WHEN WORK WILL BEGIN ASAP
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $
(Including removal of all obstruction, materials, and debris, backfilling, com-
paction and placing permanent resurfacing and/or replacing improvements)
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.
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules and regulations of the City of
La Quinta and to pay for any additional replacement necessary as the result of this work.
�moi/ � / �r { j//�� �
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Signature of Applicant or Agent 568-9411.
Murch of St. Francis of Assisi, 42-600 Bob nape Drive, Suite 115, Rancho Mirage, CA 92270
Name of Applicant (please print) Business Address Telephone No.
W. D. Gott Construction 1656 E. 9th Street, Upland, CA 91786 (714) 982-8951
Name of Contractor and Job Foreman Business Address Telephone No.
279683 City of la Quinta License #039
Contractor's License No.
;.Mate CC pensatian Insurance lend
City Business License No.
390779-32
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit —Class III
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs T„
i
Minor Improvement Permit —Class IV: See attached schedule
Inspection Fee $
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $ 01G.14
Receipt No.
Received by Date
PERMIT VALIDATION
PERMIT NO. O!' ,
DATE APPROVED tr. /� 2 i :i_
EXPIRATION DATE
DATE ISSUED
By 7.
Administrative Authority
Recorded by 11 TELEPHONE: (619) 564-2246