1102d
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NOTE:
With proper validation
this form constitutes an
encroachment permit
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CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
&MIC T2/O OVEk5/ZE /-OA0 /T�eM /T
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— 6- q l
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION MOVE EQUIf?
DESCRIPTION OF CONSTRUCTION O K DOZER
DIMENSION OF INSTALLATION OR REMOVAL
ALL ELSE LEGAL
Subdivision Improvement Permit — Class III
Minor Improvement Permit Class IV
Sketch (attach construction plans if appropriate)
HAUL ROUTE '
144IY 1// f W115HIA167TaAl. S/8
TO 50 *A EA5T //y M / L E
MAUL DATE - S- B-171
SIZE OF EXCAVATION, IF NEEDED
I P1 1 -0T CAIZ F-FOU12ED
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 int 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
PICDNI TRVCKIkIG ,l
Name of Applicant (please print) Business Address Telephone No.
MUE-0 EM(n. 3q S- /778
Name of Contractor and Job Foreman Business Address Telephone No.
bN FI. L E ON FILE
Contractor's License No. City Business License No.
OA) PILL ON FILE
Applicant's_ Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Class 111 0051$$ iiq i8g9q� 05-08-91 i0
Public improvements: 3% of estimated construction costs iq C H 1 FAL i 10.00
Private improvements: 3% of estimated construction costs O
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $
Permit Fee 10' 00
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by
Date
PERMIT NO.
PERMIT VALIDATION
1102-
0
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By__ -
Administrative Authority
Recorded by TELEPHONE: (619) 564-2246
a
l
NOTE:
With proper validation
this form constitutes an.
encroachment permit
.t
V
CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
ME TRIP OVFA51ZE IYeM /T
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: 5' S. q1 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
a
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION M 0V E' E61111P. Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION DgK DOZER AIAUL ROUTE `-
N�t1Y ll1 � !il/ASH�IiV��TG�t! S/8
TO 50 ta EA5T 1/41 M i l E
DIMENSION OF INSTALLATION OR REMOVAL J 3 �
ALL ELSE LEGAL 14AVL DATE-
�
SIZE OF EXCAVATION, IF NEEDED
!
PILOT C� I�
Z EQUI k � D
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 result of this work.
,
Signature of Applicant -or Agent
P ICA)] - TRUCK I MC-,
lel �.� '(07 7�- 81910 �
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
6Al rl L E UV FILE
Contractor's. License No. City Business License No.
DAl PILL ON FIL E
Applicant's Insurance Company. Policy Number;.
FEES: Subdivision Improvement Permit — Class 111i0 1gg'' 05"08-91 10
Public improvements: 3% of estimated construction costs 1 TQRL 1 1000
Private improvements: 3% of estimated construction costs 0
Minor Improvement Permit — Class IV: See.attached schedule
Inspection Fee $ PERMIT VALIDATION
Permit Fee 19' 00
Penalty
Cash Deposit -Surety Bond '
if,required
TOTAL: $ /0-00
Receipt No.
Received by Date
Recorded by
PERMIT NO. ' /!0?—
DATE .APPROVED
EXPIRATION DATE
DATE ISSUED
By
v
Administrative Authority
TELEPHONE: (619) 564-2246