0132N' •NOTL':
With proper validation
this form constitutes an
encroachment permit
it •
CITY OF LA' QUINTA
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
Subdivision Improvement Permit — Class I I I
DATE: _l11t1c ?_1, 1985 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION Avenida Fernando
(Street address or Description of Location)
street improv. plan�
s.
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate) f•
DESCRIPTIPN OF CONSTRUCTION bcre ' pavemen . 0Q14- o" F"e- 64MZ .
Const. 3 A.C. >oavernent,ocons ct tvmEEPS—a-Eff
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:
1CONTE70
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.
Notify the Administrative Authority at ,leasti twenty-four (24) hours in advance of the time when work will be started.
Comply with all applicable City Ordinances, the terms andconditions 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.
Sig ature of Applicant or Agent.
Ander. Copr. P. . ', 3ox 780 La Quinta, CA 92253 564--1315
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. Company Policy Number
FEES: Subdivision Improvement Permit —Class III ENTERED NOV 2 5 1985
Public improvements: 3% of estimated construction costs H�
Private improvements: 3% of estimated construction costs 1,3a
W�T..r",
Minor Improvement Permit — Class IV: See attached schedule .1AIMV
Inspection Fee $
Permit' F'ee:. • ••. 375.77
Penalty'. -
Cash Deposit -Surety Bond
if required"
TOTAL: $-37,--. 27
Receipt No.
Received by Date
Recorded by
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED 6-2.1-85
EXPIRATION DATE
DATE ISSUE % Y
By
J �
TELEPHONE: (619) 564-2246
iz/-
nistrative Authority -
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