0078} NOTE:.
With proper validation
this form constitutes.an « t CITY OF LA .QUINTA 1O
- elcroachment permit - - , k
{ APPLICATION FOR. PERMIT
PUBLIC. WORKS CONSTRUCTION (ENCROACHMENT)
...
{ 0
For the' construction of public or private curbs, drivewa'ys;'pavements,'sidewalks, parking lots sewers, water mains
and other like public'vvorks'improvements in connection with MINORIMPROVEMENTS and APPROVED SUBDIVISIONS y"
ry
Subdivision, Improvemeni,Nrmit — Class III
DATE: Jahuary 17, 1985 Mi '
• , r ' nor Improvement Permit Class IV
53-300 Avenida 'Ramirez'
' LOCATION' OF CONSTRUCTION � ._ # " •+,�' '
(Street address. or Description of Location) t
PURPOSE OF CONSTRUCTION .iiriimautav Anmin ,Sketch (attach'construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION _ ' r a ,;•,
DIMENSION OF INSTALLATION 0R REMOVAL
SIZE OF EXCAVATION, IF NEEDED < '
APPROXIMATE TIME WHEN WORK WILL BEGIN,
APPROXIMATE TIME OF COMPLETION o
ESTIMATED CONSTRUCTION COST $ • }
(Including removal of all obstruction, materials; anddebris, 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 an'd.all ,
penalties, liabilities or loss resulting, from claims, or court action and arising out of any accident; los§ `or damage to persons or property
happening or occurring as a "proximate result of'any•work undertaken under the pJrnii 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. + • ;
Complywith all applicable City Ordinances,'the"terms,and conditions of the permit and all applicable rules and'"'regulations "of the City of. ' t
"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.. Box 1040 • La Ouinta,-CA 92253 564-91901
• Name of Applicant (please print) Business Address*
Telephone No r
Rick Johnson I( Ionst'._, P.O. Box ' 2288 Indio, CA 92202- 347-7171 . • ,
Name of Contractor and Job,Foreman Business Address 'Telephone No.
.497169
Contractor's License No.' City Business License No.
Applicant's Insurance. Company Policy Number
%ob
FEES:' Subdivision Improvement Permit = Class III �; A r'
:. •
Public improvements: 3% of estimated construction costs - ` 3' , , ,w
Private improvements: 3/0 of estimated construction costs e� Q
' y 11,
Minor Improvement Permit — Class IV: See attached schedule y k / 0
Inspection Fee. $ PERMIT VALIDATION .
Permit Fee
PERMIT NO. 1-179
Penalty.. 1-17-85+
OF
ty Bond DATE APPROVED. Cash Deposit Sure r 1
if required 1 EXPIRATION DATE 1:-1786 `. !
.,
TOTAL: $
DATE ISSUED
Receipt No.
} y BY
Received by Date ". '. "a, Administrative Authority
Recorded by -77
, +TELEPHONE'., (619) 564-2246.' n+x