0099NOTE: -
,With proper validation
4 2
this form constitutes an CITY OF LA QUINTA
encroachment permit
APPLICATION FOR 'PERMIT —
PUBLIC WORKS CONSTRUCTION' (ENCROACHMENT)
r OF TIiB�
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
Subdivision Improvement Permit -_Class III _
DATE: March, 8, 1985 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 51-075 Calle Paloma
(Street address or Description of Location)
Driveway Apron
PURPOSE OF CONSTRUCTION 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 `an and `all -
Y; 9 PY
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 additional replacement necessary as the result of this work.
t S1gnature of Applicant or Agent
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 l II ;
Public improvements: 3% of estimated construction costs r4 '
Private improvements: 3% of estimated construction costs
` Minor improvement Permif = Class IV: See attached schedule No
Inspection'Fee , $ PERMIT VALIDATION
Permit Fee 20.00 = 1279
` PERMIT NO. - ,
Penalty 1
•DATE APPROVED 3,-8-85
Cash Deposit -Surety Bond �.
if required EXPIRATION DATE insconj. With. petudt ' , '
4 IOTA
L: $ 20.00 �- . , 4
r - _ DATE ISSUED s
.•• Receipt No. -
�` By. S
Received by
Date ' Administrative*Authority
• Recorded by " ^' j TELEPHONE:�(619) 564 2246 t fi;•