0287 (2)NOTE:
With proper validation
this form constitutes an
encroachment permit
CITY -OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS .CONSTRUCTION (ENCROACHMENT)
R ,
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 III
DATE: November 9,,, 1987.Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION ' W/S Jefferson 180' N/O Avenue 54
(Street address or Description of Location)
PURPOSE OF.CONSTRUCTION To provide service for Sketch (attach construction plans if appropriate)
Skins Game—
DESCRIPTIONOF CONSTRUCTION Splice in term See attached drawings
USA No.
DIMENSION OF INSTALLATION OR REMOVAL 4' X 4Splice
Date Issued:
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN 11-17-87
APPROXIMATE TIME OF COMPLETION-- ' 11-30-87
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 of the 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.
Signature of Applicant or Agent
_GENERAL TELEPHONE 83-793 Dr. Carreon Blvd., Indio, CA 342-0535
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
F .
FEES: Subdivision Improvement Permit - Class I I I.
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs NO 28�
Minor Improvement Permit - Class IV: See attached schedule
Inspection Fee $ - NZA PERMIT VALIDATION
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL': $ N/A
Receipt No.
Received by Date
Recorded by
PERMIT NO. 7
DATE APPROVED ��L �� 7
EXPIRATION DATE 1/ fl %
DATE ISSUED l�! 6 /� 7
By
Admini tive Authority
TELEPHONE: (619) 564-2246