0204I, JX
` Withraper 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
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS,
.7t]ri� 10; 36 Subdivision Improvement Permit -.- Class II I
DATE:* R• Minor Improvement Permit Class IV t
LOCATION OF CONSTRUCTION . Tradt 20717-1
(Street address or Description of Location)It
'•
PURPOSE OF -CONSTRUCTION Sketch (attach construction plans if appropriate)
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DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL _.
SIZE OF EXCAVATION;.IF NEEDED 1 )~
APPROXIMATE TIME WHEN WORK•WILL BEG�I,Nn
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, defendand 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.
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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 o�ff the permit and all applicable ules and regulations of the City of
> La Quinta and to pay for any additional replacement necessary as the fesult of this work.
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Sigria re of Applicant or Agent
National Mortgacle and Land- 75-005 Country Club. Dr. Palm -Desert 568-2828 ,
Name of.Appli cant (please print). Business Address Telephone No.
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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 III
Public improvements: 3% of estimated, construction costs . „•
Private improvements: 3% of estimated construction costs
Minor. Improvement Permit — Class IV: See attached schedule 0 2,04'
Inspection Fee-,$ 10..00 �. PERMIT -.VALIDATION '
Permit Fee 4,606.00 204
PERMIT NO.
Penalty 6-5-86
Cash Deposit -Surety, Bond DATE APPROVED
,if required EXPIRATION DATE
TOTAL: $ 4.616.00
Receipt No.
Received by Date
Recorded by ;
DATE ISSUED 6-6-86-
13y ,
Administrative.Auth.ority.
TELEP...HO•NE: (6l 9)
56472246 ;