0077r aNOTE: . • - ' +' - _ .
• With proper validation - • , ,.' � 0,4 .
• 4 "'this form constitutes an
encroachment permit CITY OF LA', QUINTA .r
' - • . APPLICATION. FORS• PERMIT
PUBLIC WORKS .CONSTRUCTION (ENCROACHMENT)
r . 'SOF TI$
.'
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 `
L
Subdivision Improvement Permit — Class III
DATE: Januar'V 17. 1985 Minor Improvement Permit Class IV:
LOCATION' OF CONSTRUCTION 53-320 Ayemi ria T?ami rn, `
_N ,
(Street address or Description of Location) • . .f
PURPOSE OF CONSTRUCTION • Driveway Apron- Sketch (attach construction plans if
. P appropriate),.
DESCRIPTION OF CONSTRUCTION -
DIMENSION OF INSTALLATION OR.REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION - F'
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 ;
g 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 of this work.
+ Signature of Applicant or Agent
Brian' -Monroe P.O. Boal: -1040 • La Quints, CA 92253 564-9190.
Name of Applicant (please print) Business Address Telephone No. y
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 I I I
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs x `,
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee PERMIT VALIDATION
Permit Fee 29.00
` PERMIT NO. X78
Penalty 1=17-85
Cash Deposit -Surety Bond DATE APPROVED
if required ,EXPI+RATION"DATE 1-17=86
TOTAL: $ 20.00. .' . Y
DATE ISS'
Receipt No.
;By. 1. o'.Ci
t
Received by Date Administrative Authority
Recorded by TELEPHO,NE:1(619) 564-2246.