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yNOTE:
With -proper validation - + ,-• �r� Q
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this form constitutes an
CITY OF QUINTA"'
`LA
encroachment permit
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION. (ENCROACHMENT)-`.�
' OF
' 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 17 ' 1985 Subdivision Improvement Permit.— Class IIIA
DATE: - Minor Improvement Permit Class -IV '
52-410 Avenida Villa * '
LOCATION OF CONSTRUCTION
(Street address or Description of Location) "
PURPOSE OF CONSTRUCTION Drii7l l y Axaron 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
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paction• and placing permanent resurfacing and/or replacing improvements)
In consideration' of the granting ofithis permit, the applicant hereby agrees to:
Indemnify, -defend and'save the City, its authorized agents, officers, representatives and employees,,harmlessrfrom 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-fourz(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 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.
Signature of Applicant or Agent
Davide Cervantes 50-223 Ilwy- 86 #29 Coaoh611a, CA. 92236
Name of Applicant (please print) Business Addresst
_ ': Telephone No.
' Name of Contractor and Job Foreman Business Address , ; ' Telephone No.,,
-
.Contractor's- License No. t City Business License.No.
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Applicant'sansu'rance Company i Policy Number
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FEES: Subdivision Improvement Permit- Class 111
Public improvements: 3% of'estirnated construction costs
Private improvements: 3% of estimated construction costs
112
Minor Improvement Permit — Class IV: See attached schedule
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' Inspection Fee $' PERMIT VALIDATION
Per`mitfee 20.00 • 1329'
PERMIT NO:'
• Penalty -DATE APPROVED 4-17-85
1'• . Cash. Deposit -Surety Bond ' •
if required r EXPIRATION•DATE t,/r eyrajt
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TOTAL: - ', -•- . ..
$ 20.00 f
DATE ISSUED
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Receipt No.. '
J .. By r.
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Received by Date Administrative Authority -
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Recorded by TELEPHONE: (619),564=2246 r.