0090NOTE:
With proper,validation
this form constitutes an,
encroach ment.,permit "
CITY OF LA QUINTA` +.
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains
and otherVlike'public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
Subdivision ImprovementPermit 'Class'lII
DATE: PAY 27, 1985 Minor Improvement Permit Class IV
-LOCATION OF CONSTRUCTION 52-470 Avenida Madero
.-(Street address or Description of Location)
PURPOSE OF. CONSTRUCTION Ftr"IIMM', Apron' Sketch (attach construction; plans if 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/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 of
La Quinta and to pay for any additionalreplacement necessary as the result of this work.
Signature of Applicant or Agent
Noel Jensen P.,O. BM 305 Rancho Ciacamm CA 714-980'-'2991
L
Name of Applicant (please print). Business Address Telephone No. •
Name of Contractor and Job Foreman Business Address Telephone No. x.
Contractor's License No. City Business License No.
Applicant's Insurance Company Policy Number i
FEES: Subdivision Improvement Permit — Class I I
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs t>l�
Minor Improvement Permit - Class IV: See.attached scheduleX.
\\`•���
Inspection Fee $ PERMIT VALIDATION
Permit Fee 20000 124
PERMIT NO.
Penalty
Cash Deposit -Surety Bond
if required'
TOTAL: $ 20.00 '
Receipt No.
Received by Date'
Recorded by
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By "
Administrative Authority.
TELEPHONE: (619) 564-2246