0104it �•�;.��
NOTE:
With proper validation `
this form constitutes an
CITY 'OF LA. QUINTA .
encroachment permit N " cv
-APPLICATIQ'N FOR. PERMIT
PUBLIC"WORKS CONSTRUCTION (ENCROACHMENT)
For the construction of public or private, curbs,' driveways,' pavements, sidewalks,
Y P parking lots,, sewers, water_ main's.
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
Subdivision Improvement'PermitF— Class III
DATE, April 11, 1985 Minor Improvement Permit.Class'IV '
LOCATION OFF CONSTRUCTION 54-225 Ai�-_ni.da Mp_ndo�a
(Street address or Description of Location)
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PURPOSE OF CONSTRUCTION Drlveway ron Sketch (attach construction plans if appropr`iate)' ''
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DESCRIPTION OF CONSTRUCTION f
DIMENSION OF INSTALLATION OR,REMOVAL ,
SIZE OF EXCAVATIONJF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
,I!
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.1or 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.
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Notify the Administrative Authority at least twenty-four' (24) hours in advance of the time when work will, be started.
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Comply with all applicable City Ordinances, the terms and conditions of the-peff it%and\\all applicable rules and regulations of the City of
La Quinta and to pay for any additional'replacement necessary as the/rtes result t of this woPk. "
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Signature of Applicant or Agent
9 Ppm
Rick Johnson : P.O. Box 2288 Indio, CA 92201 '' •347-7171
Name of Applicant (please print) Business Address Telephone No. `
Name of Contractor and Job Foreman Business Address ' ` . Telephone No.
Contractor's License No. 4"City Business License No. "
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Applicant's Insurance Company- + Policy'Number R
FEES: Subdivision Improvement Permit — Class 111'
Public improvements: 3% of estimated construction costs "
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Private improvements: 3% of estimated construction costs
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Minor Improvement Permit -Class IV: See attached schedule ' (' °;-
Inspection Fee $ PERMIT VALIDATION
' Permit Fee����
PERMITM...'
f Penalty �'• ` .t t
Cash Deposit Surety Bond DATE APPROVED'
if required
EXPIRATION DATE 61 Qit/Ya
TOTAL: • $ Q 0,00
.;
DATE ISSUED
Receipt No. ,
t
, B Y '
Received by Date ` ' OAdministrative Authority,
.'Recorded by-TELEPHONE:.(619) 564-2246 ' .