0093M1
NOTE:r-,..
Wih proper validation
this form constitutes an
encroachment 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 other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SU_BDIVISIONS'.
Subdivision Improvement Permit — Class I I I
DATE: March 5, 1985 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 51-935 'Avenida Villa r
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION DrivauraV Ammn
DESCRIPTION OF CONSTRUCTION '
DIMENSION OF.INSTAL'LATION OR REMOVAL
Sketch (attach construction plans if appropriate)
SIZE OF,EXCAVATION, IF NEEDED `` f
APPROXIMATE TIME WHEN WORK WILL BEGIN
' .APPROXIMATE TIMErOF COMPLETION
-x ESTIMATED CONSTRUCTION COST$ 1.
(Including removal of all obstruction, materials, and debris, backfilling, com-
paction
om 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 rr
penalties, liabilities or loss resulting 'from' claims or court action and arising out of any accident, loss or damage to.persons or property
t;
happening or occurring,.as a proximate result of any work undertakers 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. 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 result of th-is work. 1 ,
'Signature of Applibht or Agent
• r 4
Rick '-0'ohrMn Cmst. P.O. Box 2288 Ifi&o, CA 92201- 3 37-7171 `�
Name of Applicant (please print) Business Address 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
FEES: Subdivision Improvement Permit — Class III '
Private improvements: 3% of estimated construction cost:
Minor Improvement Permit _ Class IV: See attached schedul
Inspection Fee $
Permit Fee 2n- rn
Penalty-
Cash'Deposit-Surety Bond
if required
TOTAL: $ 2n:' nn
Receipt No. '
.r f
Received by Date'
.«:.,Recorded by
PERMIT VALIDATION
PERMIT•NO. -1246
' ;DATE APPROVED March 5, 1985
EXPIRATION'DATE Tn' isnrti. w/tmdrt ;
DATE-ISSUED-
By—
ATE-ISSUED By
Ad lstrativei Authority,
TELEPHONE: (619) 564-2246. '