0134.�-�.
NOTE:
With proper validation
this form constitutes an
encroachment permit
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(Return white copy with pa t)
CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
P.'o. Box 1504
La Quinta, CA 92253
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 III '
DATE: V L- �� 7�/ � n Minor Improvement Permit Class IV ></
LOCATION OF CONSTRUCTION /�V�- /a.� VF-t-.4As C! (.. 14L[,E S/`t/i4L0►4C
(Street address or Description of Location)
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PURPOSE OF CONSTRUCTION 4&A744Li¢9','0A✓ Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION
F7/4
DIMMENS%�OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN Jui.y ZfflW_
A5.50,505 O 7-z>
6C.,T/y• 6/f
:Toros Pf-s�•��-
APPROXIMATE TIME OF COMPLETION JC- A-
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 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 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.
. AVIA CCo CanKs7, --,A' ' S
-Name of Applicant (please print)
Signature of Applicant or Agent
Business Address
/,S -
Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No. '
42,626/47 A w- r3
Contractor's License No. City Business License No.
%iZ4 ri64-CA.s AE - 7,3 % 7R lf -9_47
Applicant's Insurance Company Policy Number e.
FEES: Subdivision Improvement Permit -Class III
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs "
..._..._ x.3.4.
Minorilmprovement'Permit'- ClClass IV: See"attached schedule
- Inspection Fee $ `�/•� ~r
Permit Fee
/D• °=
Penalty
Cash Deposit -Surety Bond
if required
TOTA _$ A? -70_ --
Receipt No
Received by Date
Recorded by Alk
'� �"'"' --'" •"PERMITVALIDATI'ON'j- "� '
PERMIT NO.
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DATE APPROVED
7 7,i
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EXPIRATION DATE
DATE ISSUED
By
Adm istrative Authority
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:' 'TELEPHONE: (619) 564-2246 ,, -7 Q li N