0092NOTE:;
With validation
proper
this form constitutes an
CITY OF LA, QUINTA
!
encroachment permit
• APPLICATION FOR PERMIT:
` PUBLIC'WORKS CONSTRUCTION,?(ENCROACHMENT)
OF
For the construction' of public ror private curbs, driveways, pavements; sidewalks, parking lots; sewers,, 'water mains' '
- and other Pike public works improvements in connection with MINOR,IMPROVEMENTS and APPROVED SUBDIVISIONS .,
-Subdivision Improvement Permit — Clas' ,%l 11 `
DATE: A1arCa1 5. 1985' Minor Improvement�Permit Class IV �' • '
' '• LOCATION OF CONSTRUCTION 54-325 "Avenida Juarez
' (Street address or. Description of Location) +.
PURPOSE OF CONSTRUCTION y^ila—rax, An*y-i► Sketch (attach construction laps if'a x
P appropriate)
,
4 t
DESCRIPTION OF CONSTRUCTION �.
DIMENSION OF INSTALLATION OR REMOVAL'—'+
f
. SIZE OF EXCAVATION, IF NEEDED
",• "APPROXIMATE TIME WHEN WORK WILL BEGIN a
'
;APPROXIMATE'TIME OF COMPLETION `
ESTI MATED. 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: IL
Indemnify,'•defend and save the City,'its authorized agents, officers, representatives and employees, harmless from and against any -and all
•
penalties,- liabilities o'- loss resulting from claims or court -action and arising out of any accident, loss or damage to persons or property
rn
happening or occurring as a proximate result of any workundertaken under the permit'granted pursuant t6 this application..
`
k r N
Notify the Administrative Authority at -least twenty-four (24) -hours in advance of the -time work be 4,
when will started:
r 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 resuit-io_i thidwork.
' ASignature of�pplicant or Agent
".
Rick Tohnson Cnnst P.O. Box 2288-' Indio, CA 92201 3477171'
Name of Applicant (please print) Business Address y Telephone No.
'
Name of Contractor and Job Foreman Business Address• ' Telephone -'No.,
Contractor's License No. City Business License No.
Applicant's Insurance Company- Policy' Number
r:
f.
FEES:' Subdivision Improvement Permit — Class I1I,'
1
Public improvements: 3616 of estimated construction costs
Private improvements: 3% of estimated construction costs �
' ® '`' 2
Minor Improvement Permit — Class, IV:- See attached schedule
. " Inspection Fee $ - "PERMIT VALIDATION
Permit Fee 20 00 1247
i PERMIT NO.
,.` Penalty
DATE:APPROVED 'MarCh 5, 1985
{
Cash Deposit -Surety Bond a.
if required EXPIRATION_ DATE In conj with permit
•'
TOTAL: $ ' 20.00 s ! Yr,,
'+
DA-TE—ISSUED
Receipt No.
By'
Received by Date.. 'Administrative Authority,'
Recorded by �. TELEPHONE: (619) 564-2246
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a.�