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0085•NOTE:., Y•t Q.. With proper validation • this form constitutes an `» CITY -OF LA QUBN.TA + encroachment permit APPLICATION FOR PERMIT -- PUBLIC WORKS 'CONSTRUCTION (ENCROACHMENT)c� ''n•. wSw�`` 4' 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 andAPPROVED SUBDIVISIONS Subdivision Improvement Permit— Class III 4 DATE: January 23, 1985 Minor Improvement Permit Class IV LOCATION OF•CONSTRUCTION 54-435 Eisenhower (Street address or Description of Location) -,PURPOSE OF CONSTRUCTION Driveway Apron Sketch (attach constructionlans if a � 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 ESTIMATED CONSTRUCTION COST $ (Including removal of -all obstruction, materials, and debris, backfilling, com- paction and placing permanent resurfacing and/orreplacing 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 persons or property happening or occurringeas•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 R i rharrl 3aatnnhnfAr 52-766 Pi aPnhnwP.r Ta (hiin;ta CA, '92253 564-1063 Name of Applicant (please print) Business Address Telephone No. t Name of Contractor and Job Foreman Business Address Telephone No. Contractor's License No. City. Business License No. Applicant's Insurance Company Policy -Number FEES: Subdivision Improvement Permit — Class III ry Public improvements: 3% of estimated construction costs ©A D Sty ` Private improvements: 3% of estimated construction costs Minor Improvement Permit — Class IV: See attached schedule Inspection Fee $ PERMIT VALIDATION - Permit Fee ' •20.00 R 11.97 • PERMIT N0. , "Penalty 1-23-85 Cash Deposit Surety Bond DATE,APPROVED , if required EXPIRATION DATE 1-23-86 TOTAL: $ 20.00 1-23=,85 DATE -ISSUE D Receipt No. ` Received by Date !• Administrative Authority' , Recorded by TELEPHONE:, (619)`.564-2246 `