0083NOTE:,jfPo�
With proper validation
this form constitutes an _� .
¢ CITY OF LA
encroachment permit .QUINTA
+ APPLICATION FOR PERMIT,
i
PUBLIC WORKS CONSTRUCTION '(ENCROACHMENT)�� ':„�•�Sw�
' ; <,
0 I E1B9
For the ;construction of public or private curbs, driveways, Lvements, sidewalks', parking lots, sewers, water mains '
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
1
' Subdivision Improvement Permit — Class III'
DATE: January 17, 1985 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 53-585 Avenida Dial
(Street address or Description.of Location)
PURPOSE OF CONSTRUCTION DilVenTdj7 Sketch (attach constructionlans if appropriate)
ppropriate)
DESCRIPTION OF CONSTRUCTION I'
DIMENSION OF INSTALLATION OR.REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN )'
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $ �' t
(Including removal of all obstruction, materials, and debris, backfilling, com-
paction'
and placing -per `
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, repres'entative's 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 orproperty
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 ad{ance of the time when work will be started.'. r~ `
' Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules and regulatioris of the City .of
,
L:a Quinta and to pay for any additional replacement necessary as the result of this work.
�.• Signature of Applicant or Agent t
S
Rri an Mnr+r� P !1 Rnx 104 r.-� c1t�i of a (A '92253 564 9190
Name of Applicant (please print) Business Address Telephone Nod
:Rick JOhnson'Const. P.O. Box 2288• Indio, CA 92202 347 7171
Name of,Contractor and Job Foreman Business Address Telephone No.
'2Q71 rQ
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
�° U
ti Minor. Improvement'Permit — Class IV: See attached schedule
Inspection Fee $ PERMIT. VALIDATION
PermitFee 20.00 - s
1186
'PERMIT NO.
J
'Penalty
' ,, . 1—'17-85
Cash Dep'osit-Surety. Bond DATE APPROVED
if required
• EXPIRATION DATE ' 1'"17'86
TOTAL: $ . 20.00 ; .
-17-85 `
• DATE ISSIJED�
Receipt No. ' 4
..
Received by Date - 'Administrative Authority
`'
Recorded by. TELEPHONE: 619 564-2246 '