0173NOTE:
With proper validation
this.forA_tonstitutes an ;
eng�tiachment.permit
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 III
DATE: 2-20--S6 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 77•-2)70 t:al l.e Chihuahua
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION -'- "-�'�'��'-�''� z'�r.:rckcLt Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION
Two 16' wide driveway approaches.
DIMENSION OF INSTALLATION OR REMOVAL See attached drawing
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $ jjvn !I J'►rJ,(J'Ijjrj' �'i ��
(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: R
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 1s'work.
Signature of Ap li ant or Agent
Osc:,,r 564-0190'
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Name of Applicant (please print) Business Address Telephone No.
owmer/ bui )_.ler
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 I I I
~ Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule fT ' y V o 173
Inspection Fe $ PERMIT VALIDATION
Permit ee PERMIT NO. 173.
Penalty t 2-20- 86
Cash Deposit -Surety Bond DATE APPROVED
if required EXPIRATION DATE 4-20-86
TOTAL: $ 40.0]
DATE ISSUED 0-20" A6
Receipt No.
Received by Date
Recorded by
F By
Administrative Authority
TELEPHONE: (619) 564-2246
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