0055 (2)M
•NOTE: ,
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: nixZ Mbe-r A.. 1AR4 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION W&3h _ng`'on and Eisenlrwex
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Unde ig round rower, telerlme Sketch (attach construction plans if appropriate)
an( C.V.T.V.
DESCRIPTION OF CONSTRUCTION install ducts for future
cable.
�0 feet a >,p) ox.
• DIMENSION OF INSTALLATION OR r �• •-� •�
` .SIZE OF EXCAVATION, IF NEEDED 1"° vaide 4" dee;.
APPROXIMATE TIME WHEN WORK WILL -BEGIN 11—c—F?4
CINKETEN
.�NT�R�� a� 9, ,
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $ n/a
(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 tf1g..perm`t and all applicable rules and regulatip q the City of
La Quinta and to'pay for any additional replacement necessary as theAiesult of this work.
Signature of Applicant or Ag6t i
i4. B joY nz ons .Wnstruction Co. P.O. 13ox 480 La Quinta 346-0109
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No. City Business License No.
453-367
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 RkKm NO Fee
Penalty
Cash Deposit -Surety Bond , M
if required r '1
TOTAL: $
Receipt No.
Received by Date
Recorded by
ENTERED NOV 2.5 1985
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED NICAMM&ARr 6, 1984
EXPIRATION DATL:b� 6, 1905
DATE .ISSUED yV V.
By
Administrative Authority
TELEPHONE: (619) 564-2246
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