0140r
NOTE:,
` .With proper validation•
this form constitutes an CITY OF LA QUINTA
encroachment permit
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
1y Subdivision Improvement Permit — Class'lll
DATE:. -JCS dy Z I �/ �� /' ^ Minor Improvement Permit Class IV -
LOCATION OF CONSTRUCTION D/' s ST C' /�a�c A . ��i4Mlt-y / Q/Ti4 C/�cl2u.�i
(Street address or Description of Location) �I
PURPOSE OF CONSTRUCTION
DESCRIPTION OF CONSTRUCTION Sff
DIMENSION OF INSTALLATION OR REMOVAL
Sketch (attach construction plans if appropriate)
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SIZE OF EXCAVATION, IF NEEDED 1
APPROXIMATE TIME WHEN WORK WILL BEGIN Z
ZZ
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:
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PaojA6 C_ •
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.
X
Signature of Applicant or Agent /
GO C,OnJS7. INC.
13 .0y, 783 �`p, �.�'SE27'
Name of Applicant (please print) Business Address_ 9�.4 Telephone No.
f,
Name of Contractor and Job Foreman Business Address Telephone No.
2.3241 A C Tom.
Contractor's License No. City Business License No.
"t_01AV 'c,1f2 /•ccs . Cn . sLG /73 T 79,6_14
Applicant's'lnsurance Company Policy Number
FEES: Subdivision Improvement Permit —Class III
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $�� �Y
Permit FeeyF�vPt��
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $
Receipt No.
Received by Date '
Recorded by
N 1140
PERMIT VALIDATION
PERMIT NO. �'yV
DATE APPROVED
EXPIRATION DATE',�S�3D
yDATE ISSUED •. Z Z �' /'�
By
s�Admin•st
, rative Authority
'
TELEPHONE: (619) 56472246. \\