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'NOTE:-
NOTE:
.With
,UVith proper validation •, •,_ , .. � �
this form constitutes an
CITY -OF LA QUINTA
encroachment permit
' 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 SUBDIVISIONS .
April" il 1985 Subdivision Improvement Permit - Class, 111'
DATE: Minor Improvement Permit Class IV
LOCATION OF'CONSTRUCTION -547215 Avenida Mendoza
'
(Street address or. Description of Location)
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PURPOSE OF CONSTRUCTION, DrSketch (attach, construction plans if appropriate) •';.' � "'�
"DESCRIPTION OF CONSTRUCTION
" DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION,.,IF,NEEDED
APPROXIMATE TIME WHENWORK WILL BEGIN '. .
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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 gut 'of any acciderit,''loss or damage to persons or property
happening or occurring as a proximate resultof-any work undertaken under the permit granted pursuant to this, application.
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Notify the Administrative Authority at least, tv�enty-f our, (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 lof fhe'City of "
La Quinta and to pay for any additional replacement, necessary as•.the result1—thil work.
Signature ofWpplicant or Agent
.•4.
Rick Johnson Const.— • P.04 ' BOx 2288 Indio, ` CA 92201 347-7171. �. }:
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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 Compariy Policy Number
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FEES: Subdivision Improvement Permit — Class III
Public improvements: 3% of estimated construction cost's
' Private improvements: 3% of estimated construction costs
-schedule 06'
Minor Improvement Permit —Class IV: See attached ,.
Inspection Fee $ PERMIT VALIDATION
Permit Fee 21ri. i? n P 1 , ;.
`PERMIT NO.
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. Penalty .
Cash Deposit Surety Bond tt DATE APPROVED;
S' A
if required EXPIRATION DATE .W� : -+�' •'
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TOTAL: $
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DATE ISSUED
Receipt No.
By r
Received by Date Administrative Authority
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