0671=f•..+ -a +oma +-: w.a 'a' ri=.e_ a.-+—+.� ...r .......+ ... w — — — r — — w w — — - w r — — .. — w — — r — — -- w — w — —',.. —r -
NOTE:
With proper validation
this form constitutes an
encroachment permit
CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
ONE OVERSIZE TRIP ONLY
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: 5/30%90
LOCATION OF CONSTRUCTION - - ---
r;
Subdivision Improvement Permit — Class I I I
Minor Improvement Permit Class IV
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION r_4rll 're- -r;e+7\r%T1r1 02 In j I
DIMENSION OF INSTALLATION OR REMOVAL AUL ROUTE,
DEWIUMS D'OR7sH TO .AVE 52
rAST = UASHIMTON NORTH OUT OF
SIZE OF EXCAVATION, IF NEEDED CITY LIMITS
APPROXIMATE TIME WHEN WORK WILL BEGIN VAUL DATE VZO/90
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 Ouinta and to pay for any additional replacement necessary as the result of this work.
Signature of Applicant or
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
QM 17TT,V. Contractor's License No. City ,B�usiiiess'L°icense No.
nnw
"WT V
Applicant's Insurance Company Policy4
Nu�mabe� n n -n'4
10 CASH i TOTAL. i ifs , ti�3
FEES: Subdivision Improvement Permit — Class I II
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
Recorded by
$ to _ Ael
Date
PERMIT NO
0671
PERMIT VALIDATION
0671
DATE APPROVED 5 /i(1 /Af1
EXPIRATION DATE .5/30,/90
DATE'ISSU ED`: / c �*
Administrative Authority
TELEPHONE: (619) 564-2246
s.t...,�../,-..-'�-.^�::v:e+•^y�_•,..�.:✓„- r..ul:<wl�.-��:"`s-'..�.�3....,-.dw�...'.:^z.-i.Ji^^-.-ti.r�:a.�.^�.r--^_.�-`-'--�r..-...�.-.---�.._.-.�...i`t--�,,;.,�.-�.^v.•.�r•._� �
. .y!.Q.?a^ :.J=.w .!'n^i+"�'"!r"' Srr•w`.2�r�'++-'^'�; +w. eY iM :.. w. .. +r ..a r M .r M M� 1W Y �. r•.er 'r..r 4. 6. a..w. aW r: 4► .ems t.�+•M +r. �. �+n w•r.-w:..�.s�w. ti r.arw o•wi.M rsu- re
NOTE:
With pr�oper.,validation
this form constitutes an
:; CITY OF LA QUINTA
encroachment p,q it �.
Ilk
- ! APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
ONE OVERSIZE TRIP ONLY
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 111
DATE: _ 5/30/90 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 CONSTRUCTION t -AT. QCti T-04"ER a_ « 10 WIDE
.HrTQ_U1r
DIMENSION OF INSTALLATION OR REMOVAL HAUL ROUTE
BERMUDAS NORTH TO AVE 52
EAST Tq WASHINGTON NORTH OUT OF
SIZE OF EXCAVATION, IF NEEDED CITY LIMITS
APPROXIMATE TIME,WHEN WORK WILL BEGIN HAUL DATE 5/3.0/90
APPROXIMATE TIME OF COMPLETION
ESTI MATED, 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.
zz
Signature of Applicant or
Name of Applicant (please print) Business. Address
elephone. No.
Name of Contractor and Job Foreman -Business Address Telephone No.
ON FILE
Contractor's .License No. City Business License No.
Applicant's Insurance Company Policy Number
nnr,<Qn 4A A.771 Aq-1A-40 to
FEES': Subdivision Improvement Permit —Class III
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costsn
Minor Improvement Permit — Class IV: See attached schedule"
Inspection Fee $
Permit Fee to
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $ ) 0 ' Ov.
Receipt No.
Received by Date
1(� GASH f TOTI•ll., i W.0(?
N! .671
PERMIT VALIDATION
PERMIT NO. 0671
DATE APPROVED 5/30/90
EXPIRATION DATE 5/30/90
DATE1SSUED t;/In/Qn
B
` ! Administrative Authority
.Recorded by II TELEPHONE: (619) 564-2246