0050m
NOTE:
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With proper validation
this form constitutes an CITY OFLAQUINTA
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: September 20, 1984 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION Tranf- NO 20151't (CI ark rimralnrxnant• r'nn, 1
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Street ImprayelWntS Sketch (attach construction plans if appropriate)•
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL PLANS AVATI.,ABLE
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN Sept Aber 14, 1984
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $ 126,000.00
(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 esult of this, work.
Signature of Applicant or Agent
Clark Devedlopment Corporation -• 50-102 Avenida ViS6a Bonita La QUinta 564-6448
Name of Applicant (please print) Business Address Telephone No.
Jack Clark Same She
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No.
City Business License No.
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Class III k
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
0
Minor u
Improvement Permit — Class IV: See attached schedule
Inspection Fee $ 3,783.00
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $ 3,783.00 PD.
Receipt No
Received by
Recorded by
Date
PERMIT VALIDATION
PERMIT NO
DATE APPROVED
EXPIRATION DATE
DCAIE ISSUED
By(L,..n \ \ \A 0 �110
Administrative Authority
TELEPHONE: (619) 564-2246
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