0067NOTE:
With proper validation
this form constitutes ani
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 II I
DATE: December 14, 1984 Minor Improvement Permit Class IV X
LOCATION OF CONSTRUCTION Avenue 52 approximately 700 feet easterly''of Washington
78-505 Avenue 52
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Install water line to Sketch (attach construction plans if appropriate)
rl+i C' racrvi rrr%
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL to install
anor..oximately 60. lineal feet of PVC across
A;ranue 52
SIZE OF EXCAVATION, IF NEEDED. 8" wide. 18" deep N/A
APPROXIMATE TIME WHEN WORK WILL BEGIN Dec. 14, 1984
APPROXIMATE TIME OF COMPLETION December 14, 1984
ESTIMATED CONSTRUCTION COST $ 1-000-00
(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 resultof thiswork.
Signature of Applic,a��nt:
r Agent
William Younq
78-182 Calle
€zorty
564-3019
Name of Applicant (please print)
Business Address
Telephone No.
Owner
same
same
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 I I
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $ 10.00
Permit Fee 10.00
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $ 20. no
Receipt No.
Received by Date
Recorded by
P A I D DEC 1 4 1984
N00 0067
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED December 14, 1984
EXPIRATION DATE Tttnp 1-4•. 1985
DATE -ISSUED Decmmber 14,' 1984
By
Administrative Authority
TELEPHONE: (619) 564-2246