0102NOTE:-'
T I
With proper validation
thisform constitutes an
encroachment permit CITY OF _LA QUINTA.
APPLICATION 'FOR PERMIT-.
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
1. 1,
OF
For the construction of public or private curbs, driveways, pavements, sidewalks, lots, sewers, water 'mains
'parki6g
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
m 'Ss III' Subdivision Improvement Permit — Class
DATE: April -9, 1985 Minor , I
Im rovenent Permit Class IV,
LOCATION OF CONSTRUCTION 51-405 Avenida Ramirez
(Street address or Description of,Location)
PURPOSE OF CONSTRUCTION 'MriverAmy Apron
Sketch,(attach constructionplans if appropriate)
DESCRIPTION OF CONSTRUCTION
;DIMENSION OF -INSTALLATION OR'REMOVAL
• SIZEbF EXCAVATION,- IF NEEDED
APPROXIMATE TIMEWHEN WORK WILL BEGIN
?
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $
(including removal of all obstruction, materials, and debris, backfilling, com-
-paction ancl�placing permanent resurfacing and/or replacing improvements)
In consideration of the granting *of this permit, the applicant hereby agrees to:
Indemnify, -deferid and save the City, its authorized agerits, officers, 'representatives and employees, harmless from and against any and all
penalties, hi ' abilities or loss resulting from claims or court action and arising out of any accident, loss or damage to persons or property
h ppehing proximate result of any work -undertaken uncle
a or occurring as a oximate r the permitL 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-resu I It of this Zk._
Signature or Agent
Dail Jennings P.O. ` Box 1341 La -.92253
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Tele'phorie, No.
Contractor's License NO." City Business License No.
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Class I I I
•Public.improvements: 3% 6f'estimated construction costs k
Private improvements: 3% of6stimated construction costs
-NV 10 n
Minor Improvement Permit = Class IV: See attached schedule
Inspection Fee PERMIT VALIDATION
TION
00
Permit Fee 0. 1318
PERMIT NO;
Penal-ty.
.Cash Deposit Surety Bond DATE APPROVED- AQXU,9: 1985'
if required EXPIRATIONDATE, .to coincide vith b1cig.
permA
TOTAL: 20.00
D.
F nA
—0
Receipt No.
Received by Date Administrative Authority
Recorded by i TELEPHONE: (619) '642246,
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