0244NOTE: . '
Withre ra I 1 t'
Ion
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
Subdivision Improvement Permit -Class I I I
DATE: Deco [% b 18. 1986 Minor Improvement Permit Class IV.
LOCATION OF CONSTRUCTION Tract 21381-3
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Subdivision Il rovements Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION
See approved plans.
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
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
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 ofthe 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
f /Signature of Applicant or Agent
Alaiinn�l Mnr#-narrc .anel Tarnr9 75-0f15 (bimty Qlub.Drive Palm Desert 568-2828
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•Corripany Policy Number.
FEES: Subdivision Improvement Permit —Class III 1
Public improvements: 3% of estimated construction costs'-
Private
osts`Private improvements: 3% of estimated construction cosis
Minor Improvement Permit — Class IV: See attached schedule 2 4
Jk'
Inspection Fee $ 5,200.00 PERMITiVALIDATION
Permit Fee 10.00 II 244
Penalty
Cash Deposit -Surety Bond
if required F (on ::file)
TOTAL:, $ 5,210.00
Receipt No.
Received by
Recorded by -
Date
PERMIT NO.
DATE APPROVED.
EXPIRATION DATE
DATE .ISSUE D
By
h_ Administrative Authority
TELEPHONE: (619) 564-2246,
A6Y;46