0076r'
With proper validation �.
this form constitutes an CITY OF LA QUINTA '- '
encroachment` permit
APPLICATION FOR 'PERMIT 5` .
�. PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)-
For
ENCROACHMENT) For the construction of public or private curbs, driveways, pavements; sidewalks, parking lots, Esewers, water mains
andother like public works improvements in connection with MINOR IMPROVEMENTS'and APPROVED SUBDIVISIONS
Subdivision Improvement Permit -— Class IFI
DATE:
January 17,' 1985 Minor Improvement Permit'Class IV
LOCATION OF CONSTRUCTION Driveway Apron "
(Street address or Description of .Location) ', , • •
et
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)
f
DESCRIPTION OF CONSTRUCTION k i'
• s
DIMENSION,OF INSTALLATION OR REMOVAL f
SIZE OF EXCAVATION, IF NEEDED'
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE' TIME OF COMPLETION i. t
ESTIMATED CONSTRUCTION COST $
(Including removal of all obstruction; materials, and debris, backfilling,'com-
paction and placing permanent resurfacing and/or replacing improvements)
A.
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 thistapplication:
Notify the Administrative Authority at least iwenty-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. t .,•
Signature of Applicant or Agent,`
• Brian.Monroe P.O.-Box 1040 Ta Quinta, CA 92253 564-9190.'- 1
Name of Applicant, (please print) Business Address Telephone No.
Rick Johnson Const. P.O. BOX 2288• Indio, 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 III®A p . JAP 7. 1963
�.
Public improvements: 3% of estimated construction costs
' Private improvements: 3% of estimated construction costs
�r
Minor Improvement Permit - Class IV: See attached schedule + ;°� �6
Inspection Fee $ PERMIT VALIDATION • '
Permit Fee 20.00 .
PERMIT NO. 1177' `
Penalty .• 1-17-85
Cash Deposit -Surety Bond DATE APPROVED
if required E P 1-17-86
TOTAL: $ 20.00
Receipt No.,
Received by Date
Recorded by
X IRATION DATE #
1-17-85 ,
DATE •ISSI•JED •�
Administrative Authority
TELEPHONE: (619) 564-2246