0070With 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. 17, 1984
LOCATION OF CONSTRUCTION 53-360 Avenida Ramirez
Subdivision Improvement Permit — Class II I
Minor Improvement Permit Class IV
(Street address or Description of Loca-ion)
PURPOSE OF CONSTRUCTION Driveway Apron Sketch (attach, construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $
(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 o tf�work. t
Signature of Applicant or Agent
Rick .Tnhnar,n
P-0- I;ov 228A Tndinr CA 92201 347-7171
Name of Applicant (please print) Business Address Telephone No.
n- It n n Is
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No.
City Business License No.
Applicant's Insurance Company Policy Number
CC 1�
FEES: Subdivision Improvement Permit — Class I II 1 Q OGC 1
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit —Class IV: See attached schedule
N° 970:'
Inspection Fee $
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
20.00
$ 20.00
Receipt No:
Received by Date
Recorded by
PERMIT VALIDATION
PERMIT NO. 1138
DATE APPROVED December 17. 1984
EXPIRATION DATE
�MM(' MY /JU�ne. 17. 1985
DATE ISSUED �—�` 1--U"�
By
Administrative Authority
TELEPHONE: (619) 564-2246
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