0016NOTE:
With proper validation
this form constitutes an
encroachment permit
0
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 II
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION " �:t� r'd l3raa c"', VcI-ajCn
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION17. 'j Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION AZ -11-031,L2112 F00't Of
c`Z";C, n.,F 506 I -an- in
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED 2`10—LOPS
APPROXIMATE TIME WHEN WORK WILL BEGIN'
71,0c -1-,'),. c7f 13, s�J�
APPROXIMATE TIME OF COMPLETION L ((; 2- „ill ° , O000 Or 1� v 19^ 3
ESTIMATED CONSTRUCTION COST $ Ll� U0V, a ('+ ifl
(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.
Signature of Applicant or Agent
Jo �;; o eC�" 1„ �OE'1 �tia�,'4��;�0' �t�•l;� dam" o m o ii o L?)®s'a°' i, `� -,-i �crt,,'�,� �-,� j 3 d,
Name of Applicant (please print) Business Address Telephone No.
n sa
L_S: s�,! ClV`I�-;C w��s!®p �-'
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No.
City Business License No.
's1 "e" � d
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Class I II
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
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by 'bate
Recorded by
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
TELEPHONE: (619) 564-2246
NOTE:
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
DATE: Dec. 12 1983
LOCATION OF CONSTRUCTION
Subdivision- Improvement Permit — Class III
Minor Improvement Permit Class IV
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Instal --Water Line Sketch (attach construction plans if appropriate)
DESCOJPTJ�N. OFNCOVSTRUnTJON6 Replace 63 ft.
OJPTJ�N. OF COVSTR�CTR
wa, er n O�6 I't. 6" mai
p acemaln
DIMENSIO": CF 1",lS'7.'.-,LL_ATION OR REMOVAL
SI440F E6Eea ATION, IF NEEDED Two feet wide
APPROXIMATETIMEWHEN WORK WILL BEGIN 8 A.M.
Dec 13
APPROXIMATE TIME OF COMPLETION 4 P.m.. Dec . 13
ESTIMATED CONSTRUCTION COST $ •$ 4000 . 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.
, ZSignature of Applicant
-,T-W- Moffitt Const Co P.O. Box 304 Palm Desert 347-3254
Name of Applicant (please print) Business Address -Telephone No.
James Moffitt 83491 Emerald Av.-Indio 347-5256
Name of Contractor and Job Foreman . Business Address Telephone No.
A 350561
City Contractor's License No. � - ,f ;� Y Business License No.
Insurance Company Of North Amercia Ga 502 67 24
Ap licant's Insurance Come my Policy Number
FEES: Subdivision Improvement Permit —Class III
Pubic improvements: 3% of estimated construction costs