0113' NOTE:
With proper validation _ 2
this form 'constitutes an
t e
=CITY OF �L'A QUINTA
ncroachment permit'
'APPLICATION' FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT) �� I•r���Sw�� '
- 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'. • 4
Subdivision Improvement Permit —Class, III
DATE: April 19, 85 + Minor Improvement Permit Class IV - .!
LOCATION OF CONSTRUCTION 53-345 Avenida Madero '
(Street address or Description of Location) t
"PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)..
DESCRIPTION OF CONSTRUCTION`
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, I,F NEEDED 4 �•
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME.OF COMPLETION
.,.t ESTIMATED CONSTRUCTION COST $ l r
'(Including removal of all obstruction, materials; and debris, backfilling, com-
paction and placing permanent resurfacing and/or replacing improvements) I
In consideration of the granting of this i
g g permit,, the applicant hereby. agrees to:
Indemnify,'•defend and save the City, its authorized agents, officers, representatives'and employees, harmless from arid'against'any and'all
I' �•. 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. result of this work. "
Signature of Applicant or Agent St•
Tom Hartung 53-777 Avenida Villa, La Quinta, CA .564"3170' :
Name of Applicant (please print) Business Address . Telephone No.
Name of,Contractor and Job Foreman Business Address Teleplione No: 'F '
Contractor;% License No. City Business License No..
Applicant's Insurance Company Policy Number `
FEES: Subdivision Improvement Permit — Class I I I ;.
Public improvements: 3% of estimated construction costs `
Private improvements: 3% of estimated construction costs
Minor Improvement Permit— Class IV: See attached schedule
' Inspection Fee $PERMIT VALIDATION
`t Fee 20.00 1339
Permi ,PERMIT N0:• ` .
Penalty - 4-19-85, , ,
'x
DATE APPROVED,
Cash Deposit -Surety Bond
if required ' EXPIRATION`DATE 1-712ennit•
t.
TOTAL: ' $ 20.00 X/_ 01
�. DATE ISSUED,
`Receipt No.By
{- Received by Date * Administrat ive-Au thority
Recorded by -TELEPHONE: (619) 5642246
x