0631 (2)6
JOTE: r T
Vith proper validation
his 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
i
' . l
M I I Subdivision Improvement Permit — Class III
DATE: lel �Q , Minor Improvement Permit Class IV
,.
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTIONG�—
t�, Lv�Q I� +n�fio 11 -d
DjA EN$10 i OF INSTALLAT ONORPAOVAL(777 "er Five. p
SIZE OF EXCAVATION, IF NEEDED
l
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION q0-
ESTIMATED CONSTRUCTION COST $
(Including removal of all obstruction, materials; and deb: -is, backfilling, coin- .
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 properiy
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 It of It4s rk.
r\ r
V LJ
Signa t re of Applicant or Agent �.
Vame of Applicant (please print) Business Address Telephone No.
u • �C_i1M- Di* G�l'r1 C�. uc-rU
Vame of Contractor
and Job Foreman Business Address Telephone No.
:ontractor's License No.. City Business License No.
>pplicant's Insurance Company Policy Number
:EES: 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
_..
NUEVO: ENGINEERING; INC.
79-811 COUNTRY CLUB DR.. PH. 619-345-1778
BERMUDA DUNES, CA 92201
PAY TO TH E
ORDER OF
019
N°
132
so -tea
1222
OLLARS
e
AV Trus] . Indio oHIDa
45900 Fargo SL
� BOrrk'
"Indio,' CA 92201 "
Ma,evll/6C � e 4
u'000 L 3 211;. �:a 2 2 20 2B&31:- :0 36.943.9911'80
w' THIS CHECK IS DELIVERED FOR PAYMENT ON THE ACCOUNTS SHOWN ABOVE.
NOTE':
Aih proper 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
DATE: ► IsLe 1 t 1 I f
t
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
Subdivision Improvement Permit —Class III
f Minor Improvement Permit Class IV
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION PCI Ac_
to hj�SY� l`1�gto» �b
DjI fN�ION OF IySTALLATION ORFMOVAL ap ue_
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 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 reAult of tNs %vork:
Signat rejof Applicant or Agent
Vr u,b c- 34 ;-I -7
Name of Applicant ( lease print) Business Address Telephone No.
L� 3�l'7- �1d arr►C� ��. burr e�
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No. City Business License No.
Aye ri�u r nC2_ ��I 5 ( -1
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit —Class 111
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by Date
Recorded by
N°
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE'
DATE ISSUED
By
Administrative Authority
TELEPHONE: (619) 564-2246