0199+'1
NOTE:
With proper validation
this forrri�cor"asti'tutes 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
June 4, 1986 Subdivision Improvement Permit — Class I I I
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION Calle Ensenada from Avenida Bermudas to Avenida Obregon
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Domestic water line improv.
DESCRIPTION OF CONSTRUCTION water line
DIMENSION OF INSTALLATION OR REMOVAL
See CV%D drawing
SIZE OF EXCAVATION, IF NEEDED
Sketch (attach construction plans if appropriate)
Permit is for installation and mint. of
2900 feet of 12 inch water line and
appurtenant work. The attached.
general and special provisions are
included and made a part of this
permit.
APPROXIMATE TIME WHEN WORK WILL BEGIN June 6, SEE Encroachr nt Permit # 188. `
APPROXIMATE TIME OF COMPLETION July 30, 86 O D
ESTIMATED CONSTRUCTION COST $ C
O
K(Including removal of all obstruction, materials, and debris, backfilling, com LL��
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 whenw k will be started.
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applica a rules and regulations of the City of
La Quinta and to pay for any additional replacement necessary as the result oft ork.
Snature of pp icant or Agent'
Massey Sand and Rock Co. 43-850 Monroe Street Indio 347-8535
Name of Applicant (please print) Business Address Telephone No.
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 II =�-1
Public improvements: 3% of estimated construction costs Private improvements: 3% of estimated construction costs Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $ 300.00 /fid PERMIT VALIDATION
Permit Fee 10.00 PERMIT NO. 199
Penalty 6-4-86
Cash Deposit -Surety Bond DATE APPROVED
if required EXPIRATION DATE 8-30-86
TOTAL: $ 310.00 6-4-86
DATE ISSUED
Receipt No. By
Received by Date Administrative Authority
Recorded by TELEPHONE: (619) 564-2246
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