0114NOTE:
• With proper validation'-. � r - +•� � • �.4 •
this, form constitutes an
encroachment, permit ,
CITY OF LA OUINTA' ; F.
I APPLICATION r FOR "PERMIT ' '�• •r ,r' �� .
- PUBLIC , WORKS. CONSTRUCTION (ENCROACHMENT):
` OF9ti
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
Subdivision Improvement Permii — Class III
DATE: April 23, 1985.Minor Improvement Permit Class IV,
LOCATION OF CONSTRUCTION 54-335 Ave. Martinez
(Street address or Description of Location),
t
PURPOSE OF CONSTRUCTIONT?�I1�rpti��=t+n Sketch attach const�uction'plans if appropriate)
DESCRIPTION•OF CONSTRUCTION • w '. '
. r . �K' is .. • rw w
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, coni-,
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. r r
Notify the Administrative Authority.at'least twenty-four (24) hours in advance of the time when Work vvill 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
s Rink ',Tnhnson ('nnst PO;. Rnx 22RR Tnain r - A22(11 i
Name of Applicant"(please'peint) Business Address • •Telephone No. }
Name of Contractor and Job Foreman Business Address • . Telephone No.
? Contractor's License No. f 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 ;114'F r.• .'4 : ,
Inspection Fee $ " PERMIT. VALIDATION �+ ' •'
tPermit Fee 20.00, ' ' `'` 5' 0` {'
.PERMIT NO. 4
Penalty
Cash Deposit Surety Bond i DATE APPROVED April 23, '1985 1+
if required .+ r, w�perndt
EXPIRATION,DATE� •'f
' TOTAL: t $ 20:00
r , $ ' r " DATE ISSUED
Receipt No. ,. ""
' Received by ` Date By Administrative Authority
' Recorded by 1: "�,` TELEPHONE: (619) 5642246 .R •'t; �'
• '
4
i�'? r r•• $, ' .+ �� r �lkh U U UIN' r