1096♦ A
NOTE:
With proper validation
this form constitutes an
I CITY OF •LA QUINTA
'F encroachment permit
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 `
°May 2, 1191 Subdivision Iinprovement Permit -'Class III
,,DATE; " Minor Improvement Permit Class IV
LOCATION,OF CONSTRUCTION 53-410 Martinet ,La Quinta F
(Street address or Description of Location) driveway approach �y
PURPOSE OF CONSTRUCTION . Sketch'(attach construction plans if appropriate)' -
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL 6'20 ;
! ' . SIZE OF EXCAVATION,IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN 511021
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)
c
-In consideration of the -granting of this permit, the applicant hereby agrees'to
Iridemnify, 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, .lossor damage to persons or property _
4 happening or occurring as a proximate result of any work undertaken r 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.
A 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
". Alex Torres 81-852 Paseo Real Indio
Name of Applicant (please print)Business Address Telephone No..
Name of,Contractor and Job Foreman _ Business Address• , Telephone No.
r 550498 r1',on- file
Contractor'sticense No. ` City Business, License No.
` State,Fund
Applicant's.lnsurance-Company r Policy Number,'
FEES: Subdivision Improvement Permit -Class III 005igg i0 1783 05-02-91. 0
10 ,.,_C SH i TAL -i ` 30.00
Public improvements: 3% of estimated construction costs _ �+
Q 9,V .
' Private improvements: 3% of estimated construction costs "' t
Minor Improvement Permit - Class IV: See attached schedule
Inspection Fee $ 20.00 PERMIT VALIDATION
10.00
Permit Fee PERMIT NO. log
Penalty
Cash Deposit -Surety Bond DATE APPROVED
if required EXPIRATION DATE
30.00
TOTAL: $
DATE ISSUED S Z
Receipt No. By
Received by Date Administrative Authority
Recorded by - TELEPHONE: (619) 564-2246
NOTE:
With proper validation
this form constitutes an CITY OF LA QUINTA
encroachment permit
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
May 2, 1491
Subdivision Improvement Permit — Class III
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 53-410 Martinez La Quints.
(Street address or Description of Locafionl driveway approach
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL 6120
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN 522041
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) i
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
Alex Torres 81-852 Paseo Real Indio 775-1197
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
550498
Contractor's License No.
State Fund
on file
City Business License No.
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit - Class I II 1005182 10 003 05-02-91L 130.00 i0
Public improvements: 3% of estimated construction costs O n
Private improvements: 3% of estimated construction costs 7
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
$ 20.00
10.00
30.00
Receipt No. _
Received by Date
Recorded by
M
PERMIT VALIDATION
TELEPHONE: (619) 564-2246
lorl
PERMIT NO.
DATE APPROVED
�:5-
EXPIRATION DATE
DATE ISSUEDBy
`y
Administrative Authority
TELEPHONE: (619) 564-2246
fv&E: ,
With Proper validation
F
this form constitutes an
.encroachment permit CITY OF LA QUINTA=