0080With proper validation ` ;,•t;. Q
this form cohstitutes an ' • � �4 � -'� f
CITY' OF LA QUINTA
encroachment permit
APPLICATION FOR PERMIT
F PUBLIC WORKS, CONSTRUCTION .(ENCROACHMENT)r
• '�. �' 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,
Subdivision Improvement Permit — Class - ll l
DATE: January 17, 1985 + Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 53-575. Avenida Diaz
(Street address or Description of Location) `
PURPOSE OF CONSTRUCTION Driveway APS, • }
— • Sketch (attach 'construct ioniplans if appropriate)• '+ •'`
DESCRIPTION OF CONSTRUCTION .
DIMENSION OF -INSTALLATION OR REMOVAL r . '
SIZE OF EXCAVATION, If -NEEDED , {� -;•
APPROXIMATE TIME WHEN WORK WILL BEGIN ;
APPROXIMATE,TIME OF COMPLETION ' y'
ESTIMATED CONSTRUCTION COST
(Including' removal of all obstruction, materials, and debris, backfilling, com-
paction
om paction and placing permanent resurfacing arid/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 agairist 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 toithis,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. J
La Quinta and to pay `;for any additional replacement necessary as the result of this work,
}r, Signature of Applicant or Agent ,
-Brian Monroe P.). Box 1040 .La Quints, CA 92253 564-9190.
Name of -Applicant (please print) Business Address ,;; 'Telephone No.
Rick Johnson Corist. P.O. Box'2288 Indio, CA 92202, 347-7171
Name of Contractor and Job Foreman Business Address y Telephone No.
.397169
Contractor's License No.City Business License No. '
Applicant's Insurance Company $. Policy Number, - ..
FEES: Subdivision, Improvement Permit' -Class III 4`
Public improvements: 3% of estimated construction costs
Private improvements: 39/o of estimated'construction costs ' ,1,q1��� '/�",�p
•(
Minor Improvement Permit — Class IV: See attached schedule P1.° S/
Inspection Fee $ PERMIT •VALIDATION +
Permit Fee 20.00 1181' h
PERMIT NO.
Penalty r.
Cash Deposit --Surety Bond ^ DATE. APPROVED 1-1-7R5
if required EXPIRATION DATE 1=17-86 a
TOTAL: $ 20.00 • - ,
1-.17-,$5
> . . , •DATE 1SSU-pD� -
Receipt No. ` �r� �,.
By A�o=J�/7)
Received by Date ', Administrative Authorit
Recordedby 'TELEPHONE: (619)-564-2246 '