0105' NOTE:, c
With proper validation 2
this form constitutes an CITY OF L'A QUINTA- `
encroachment permit
' APPLICATION_ FOR PERMIT —
PUBLIC r -WORKS ..CONSTRUCTION (ENCROACHMENT)��
t ` . OF Ti189
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„
April 11, 1985 Subdivision Improvement Permit — Class 111.
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 54-218 Avenida ,M,en+doza
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION — DrlffeWalr AAron 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 any and all
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 resultt 0 this work.
,Signature of Applicant or Agent
• Rick Johnson Oonst. 'P.Q. 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. City Business License No.
i
Applicant's Insurance Company Policy Number ..
FEES: Subdivision Improvement Permit — Class I II
Public improvements: 3% of estimated construction costs.
Private improvements: 3% of estimated construction costs
' Minor''Improvement Permit Class 1V: See attached schedule`
Inspection Fee $ PERMIT VALIDATION
Permit Fee 14
PERMIT NO. c
Penalty_
Cash Deposit -Surety Bond DATE APPROVED'
if required EXPIRATION DAT_ E/��
TOTAL: $1�, t��1 I ..
DATE ISSUED
Receipt No. z
By ,
Received by Date Administrative Authority
7 Recorded by R' TELEPHONE: (61 ► 564-2246 .