0075NOTE:
17
With proper validation
this form constitutes an
CITY ' OF QUINTA
,LA
encroachment permit -
. APPLICATION FOR 'PERMIT
;
#• PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)i• �•••
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0
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:,
Jari 17 1985 -.Subdivision Improvement Permit — Class III
u`�y °
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DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 53-935 Avenida Villa ,
' (Street address or Description of,Location)
i
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 andlacin '
p g 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 -oi� 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 th%is application.
j
j•
Notify the Administrative Authority at least twenty-fou"r (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.
i
Signature of Applicant or Agent
Brian; Monroe P.O. Box 1040 'Ta QUinta, CA' 92253 564=9190
Name of•Applicant (please print) 4 Business Address Telephone No.
F
Rick Johnson Const..- P.O. BOX 2288.. iictio,'CA 92202 347-7171
Name of Contractor and Job Foreman Business Address ' Telephone No.
397169
Contractor's License No. City Business License No.
Applicant's.Insurance Company Policy Number
FEES: Subdivision Improvement Permit -Class IIIP A j p SAN 1 7 1985
Public improvements: 3% of estimated construction costs.' ;
Private. improvements: 3% of estimated construction costs 4` •
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Minor Improvement Permit = Class IV: See attached schedule
t
Inspection Fee $ PERMIT VALIDATION
Permit•Fee 29:99' 1176
-'
- PERMIT NO.
Penalty
Cash Deposit-Surety-Bond , DATE APPROVED 1=17—RS
; r y-
ifrequired EXPIRATION DATE1-17- 6•
TOTAL: $ 26:00 ,
`DATE `1-17_-5
ISSUED
' Receipt No. �
- ( C t
'
Chi.% .
By '� ., . 03
Received by Date 'Administrative Authority
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Recorded by TELEPHONE: (619):564-2246