0089NOTE:f
With proper validation•
this form constitutes an CITY OF LA QUI NTA
encroachment permit
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APPLICATION FOR PERMIT
' • PUBLIC WORKS CONSTRUCTION (ENCROACHMENT) .
OF
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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 '
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e Subdivision Improvement Permit — Class I11-.
DATE: Febrtzaxy 27, 1985 Minor Improvement Permit Class IV
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LOCATION OF, CONSTRUCTION 50 Avenida Carranza2
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(Street address or Description of Location)
PURPOSE OF CONSTRUCTION.1 Drivewav Ori
_ _ Sketch (attach construction plans if appropriate)
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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/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 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 of1'. '
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.La Quinta and to'pay,•,for, any additional replacement necessary as the of this work.
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SSig1nature 4Applicant or Agent
i ,TosenhCaroini 51-750 Av¢6da Diaz La Quints, -CA 92253
Name of Applicant (please print) Business Address Telephone No.
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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
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction.costs
Minor, Improvement Permit — Class IV: See attached schedule
Inspection Fee $ + PERMIT, VALIDATION
Permit Fee 20.00 1235;
PERMIT NO:.' -
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Penalty
Cash Deposit Surety Bond DATE APPROVED
if requiredtO
EXPIRATION DATE
TOTAL: $ 20.00
DATE ISSUED ALA
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Receipt No.
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By
t= '' Received by, Date £ Administrative Autfiority r
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-� Recorded by TELEPHONE: (619) 564-22.46