0191NOTE:
With proper validation
this form constitutes an
encroachment 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 r
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
May •12, 1986 Subdivision Improvement Permit — Class III
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION Within the Paved and earth sections Of various La QUinta :roads
within the boundaries of S. CA. GAS CCHPANY operating area.
(Street address or Description of Location)
r '
PURPOSE OF CONSTRUCTION ' BIANM PST Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL Not more than 80
lin. feet excavated under blanket permit.
SIZE OF EXCAVATION, IF NEEDED 3' x 4' bell holes and
installation of new services.
APPROXIMATE TIME WHEN WORK WILL BEGIN NOTIFY CITY
24_HOURS IN ADVANCE OF ANY WORK.
APPROXIMATE TIME OF COMPLETION Permit expires 12-31-86
ESTIMATED CONSTRUCTION COST $ NA
(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.
Signature of Applicant or Agent
Southern California Gas ompany P.O. Box 2200 Riverside, CA 92516 (714) 369-4512
Name of Applicant (please print) Business Address Telephone' No.
Name of Contractor and Job Foreman
Contractor's License No.
Business Address
Telephone No.
' A
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
Inspection Fee $ -0-
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by
Recorded by
$ -0-
Date
PERMIT VALIDATION
PERMIT NO. 191
DATE APPROVED 5-12-86
EXPIRATION DATE 12-31-86
DA�TE`ISSUED 5-12-86
Administrative Authority
TELEPHONE: (619) 564-2246