0168�. NOTE: Y
XWith roper validation.'
fom constitutes an
encroachment permit
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CITY OF LA° QUINTA r
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APPLICATION FOR PERMIT' ""•
PUBLIC WORKS CONSTRUCTION -(ENCROACHMENT)
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For the construction of public or private curbs, driveways, pavements, sidewalks', -parking- Iots',l sewers, water mains
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
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Subdivision Improvement Permit — Class III
DATE: tTantaam.16, 1986 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION _J :a= 78-Oeib�Caile Estado,:
(Street address or Description of Location)
PURPOSE�OF CONSTRUCTION Curb,' gutters and SldnvJallC. Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION-`
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DIMENSION OF INSTALLATION OR REMOVAL
Per City Standards # 204
207
401 4
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) -
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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;'Iiabilities or loss resulting from claims or court action and arising out of any accident, loss or damage to persons or property
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happeningoroccurring 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 Quirita and to pay for any additional'replacement necessary as the result of this work.
s gnature of Applicant or -Agent
R Ck�Johnson,Construction* -" P.O. Ta Quinta, CA 92253 564•-2228
Name of Applicant. (please print) . Business Address Telephone No.
Dateland Construction
Name of Contractor and Job Foreman Business Address Telephone No.
C"pntractor's License No. City Business License No.
'. plicant's Insurance Company I�,. I ,r'`r< PolcyiNumbe�l . pt
FEES: Subdivision Improvement Permit=tClass III
�r}I t i•'; �� Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minok' Improvement Permit — Class IV: See attached schedule
Inspection Fee $ 10 -.00
,Pei .!V , Fee
66.00=
• Peraai�y .
Pe Bis it -Surety Bond
•if regt�ifgd
TOTAL: $ 76.00
Receiq4,„N�0,
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Recei%Aaby Date
" EN1.ER�D JAN 2 �
" _ •�� X68 •
PERMIT VALIDATION
PERMIT NO. 168
DATE APPROVED 1-16-861- y
EXPIRATION DATE 2-16-86
DAT1-16-861-16-86
By -
Administrative Authority
TELEPHONE: (619) 564-2246
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1 16 76,00 CK
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