0202NOTE.
With*proper validation4' •"
this formci°
_on`sttutes 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
and other like public works improvements -in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
' Subdivision Improvement Permit — Class 111 '
DATE: June 10,' 1986 Minor Improvement Permit'Class IV
LOCATION OF CONSTRUCTION Tract '20717-2 'PGA WEST '
(Street address oriDescription of' Location). +
PURPOSE OF CONSTRUCTION Sketch (attach'construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION '
ATTACEIM
DIMENSION OF INSTALLATION OR REMOVAL
SIZE.OF EXCAVATION, IF NEEDED 41
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)
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 5,
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.
'f Notify the Administrative Authority 'at least twenty-four (24) hours in advance of the time when work will be started.
l., 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 t e r s It f this .work.
!�Cgnatu a of Applicant or Agent N
National Mortcrage and Land 75-005 Country Club Dr. Palm Desert 568-2828
Name of Applicant (please print) Business Address Telephone No.
smie :
Name of Contractor and Job Foreman Business Address Telephone_No.
Contractor's License No.- City Business License No:
Applicants Insurance Company. Policy Number'
'FEES: Subdivision Improvement Permit — Class I I I s
Public improvements: 3% of estimated construction costs
P . 30 f
r vate improvements. /o o estimated construction costs
Minor Improvement Permit —'Class IV: See attached schedule
Inspection Fee �` ..� $
10.'00
v
Permit Fee � `'��-
11,048.00
Penalty
Cash Deposit-Surety'Bond' -
if.rrequired
TOTAL: $
n';A _ On
Receipt No.
Received by
Date
Recorded by
2(12
PERMIT VALIDATION
PERMIT NO* 202"
DATE APPROVED June 6-86
EXPIRATION DATE
DATE ISSUED June 10. 86
By
Administrative Authority
_ TELEPHONE: (619) 564-2246