0210 (2)'4
NOTE:.'.
With proper validation
this form constitutes an
encroachment permit
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CITY OF LA-QUINTA
APPLICATION FOR • PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
For the f
construction of : public or private curbs, driveways, pavements, sidewalks, parkinglots, sewers, water mains ,
and other like public works improvements in connection with MINOR. IMPROVEMENTS and APPROVED SUBDIVISIONS
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July. 3, 1986 Subdivision Improvement Permit — Class I I I
DATE:' Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION Madison Ave. 1/4 mile south of Airport Blvd.
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION pipeline installation Sketch (attach construction plans if appropriate)
crossi.ncT street
DESCRIPTION OF CONSTRUCTION 1 10° -SDR 26 class 160
PVC pipe aoprax. 100® in lenqth 3' frau Permit is for the installation and
maintenance of a 10 --inch waterline.
DIMENSION OF INSTALLATION OR REMOVAL 3' X 28' Of
pavement surface diactonally See attached sketcL The attached
Special and General Provisions are
SIZE OF EXCAVATIONJF NEEDED 4' depth included and made a part of this
permit.
APPROXIMATE TIME WHEN WORK WILL BEGIN 7-8-86
APPROXIMATE TIME OF COMPLETION 7-8-86
ESTIMATED CONSTRUCTION COST $ 2.500.00
„(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:
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Indemnify, defend and save the City, its authorized agents, officers, representatives and employees, harmless from and against any and all
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.penalties, liabilities or loss resulting from claims or court action and arising out of any accident, loss or damage to persons or property .
it 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 when works ill be "started'
Comply with all applicable City Ordinances, the terms and conditions of the perrriit andall applica le rules and regulations of the City of
+ La •Quints and to -pay for any additional replacement necessary as the result of this wo/rkk.
I igrure of Applicant or Agent
•Lanclndrk Land Ca Tpany of CA Inc. P.O. Box 1000 La c uinta 564-4463
Name of Applicant (please print) Business Address Telephone'No.
Paul Quill same
Name of Contractor and Job Foreman Business Address Telephone No.
413616
Contractor's License No. City Business License No.
Applicant's Insurance Com
FEES:
Policy Number
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Subdivision:lmprovemeni 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 $ 40.00
Permit Fee 10„00 II
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:.
Receipt No.
Received by
Recorded by
Date
N� 21®
+ PERMIT VALIDATION
PERMIT NO. 210
DATE APPROVED 7-1-86 '
EXPIRATION DATE 8-8--86 ,
DATE ISSUED 7-2—f16
By
Administrative Authority
TELEPHONE: (619) 564-2246
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