0117. NOTE:
With, proper validation - Q
this form constitutes an CITY OF LA QUINTA
encroachment permit
r APPLICATION FOR PERMIT - -
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
For the . construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains
jF and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS .
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Subdivision Improvement Permit — Class II I
DATE: Ani -i1 26. 1985 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 54-395 Fa cP h,r_r '
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Driveway apron 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 employ ees,•har'mless 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.
Complywith 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.
i Signature of Applicant or Agent
Clint Dougherty P.O. Sox 1420 La QUinta, CA. 92253
Name of Applicant (please print) Business Address' Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No. > .
E - -
Contractor's License No. City Business License No.
' Applicant's -insurance Company Policy Number
FEES: Subdivision Improvemerit Permit — Class I II'
Public improvements: 3% of estimated construction costs ..
Private improvements: 3%.of estimated construction costs,
Minor Improvement Permit — Class IV' See attached schedule 117
..
Inspection Fee $ ' " PERMIT,yALIDATION '
• Permit Fee 20_00 PERMIT NO. 1357'
Penalty . '4-26-85
Cash Deposit -Surety Bond DATE APPROVED
if required
EXPIRATION DATE, 'wIAern1].t ,.
$ 20.00 ;
TOTAL: DATE ISSUED ~
Receipt No.
By
Received by Date Administrative Authority
Recorded 6y TELEPHONE: (619) 564-22.46
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