0013NOTE:
With proper validation
this form constitutes an
encroachment permit
•
CITY OF LA QUINTA
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 I I I
DATE: OC:ObCr 14, 1983 Minor Improvement Permit Class IV XX
LOCATION OF CONSTRUCTION 50th Avenue - Approximately 2000' west of jrasshingtan St.
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Electrical Service to Sketch (attach construction plans if appropriate)
Tract 18767
DESCRIPTION OF CONSTRUCTION Road Crossing
DIMENSION OF INSTALLATION OR REMOVAL 50 LF of
Pavement Removal
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION One OaV W/rTeM. PaVE3Cl MO
ESTIMATED CONSTRUCTION COST $ 1000.00
(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.
.0
Signature of Applicant or Agent
Vic's ,Backhoe Sexvice 7757 Sage, Yucca Valley, CA (619) 365-1405
Name of Applicant (please print)
Business Address
Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No.
Ham Insurance Cmpmy
City Business License No.
BM8827902
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
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $
Permit Fee IMM 53.00
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by
Recorded by
$ 53.00
Date
113 .
PERMIT VALIDATION
PERMIT NO.�
DATE APPROVED A00�4 /? 1s
EXPIRATION DATE
DATE ISSUEDBy
i/ Administrative Authority
TELEPHONE: (619) 564-2246
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' TO.fN-'STA LLATION CSE CON DUfTS,_PULLBOXES, ANN TRAf4S;Fi -44EI -,
PADS.
it I D. WILL INSPECT ALL CONOU IT ' RUNS,'PULL BOY, S' TAgS-
F'ORIAER .PADS TO BE OCCUPIED ESY I'.. I D., PRIOR TO 8ACK FILL
AND/OR CONCRETE. POURS, CONT RACTOR SHALL "NOT(F* I. III
�4 HOURS PRIOR TO INSPECTION.,
6.' CONTRACTOR SHALL BEL RESPONSIIaLB F`OR RESTORING TO.iT`�a.'
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EORIMER CONEL)ITION AS NEARLY AS POSSIBLE +°1LL EXCA` ATi��_:':
: AREAS F THIS WORK AND C01NAPACT ALL�,.AC14F;LL--TO 9G.Yo
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