0054NOTE:
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 III
DATE: 17, 1984 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION Washin4ton and Miles. Washington to Hwv 111 (Wash.inaton
and Fred Waring, Tract 18915)
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION On and Off Site Improvements Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION CUrb & Critters
Street Water and Sewer
DIMENSION OF INSTALLATION OR REMOVAL 400 sg. ft. PLANS AVAILAB,L,E
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $ 540,742.00
(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.
S�N�S
M,�, x�si Prl
Name of Applicant (pleas2 pri
of Contractor and Job' Foreman
Contractor's License No.
Applicant's Insurance Company
FEES: Subdivision Improvement Permit — Class I I I
ure of Applicant oyfAgent
ss Address
Business Address
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.
8,900.00
$ 8,900.00
Received by Date
Telephone No.
Telephone No.
City Business License No.
PERMIT NO
,&0 RECEIVED
TV0 1 5f ..1984
BUILDINGFDEPARTM NT
PERMIT VALIDATION
DATE APPROVED f L 1S - EL(
EXPIRATION DATE Ll— 19 " g Zr
DATE"I`S1SU.ED ty' �9'/
Administrative Authority
Recorded by 11 TELEPHONE: (619) 564-2246