1194 (2)NOTE:
With 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
Subdivision Improvement Permit — Class I I I
DATE: R-71 —ql Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION CATTY SONDRA AT VART(VTS T OCATTr1NS
(Street address or Description of Location)
I PURPOSE OF CONSTRUCTION
p ��1;9614F�$�1.5 MA -Z 1 FOR Sketch (attach construction plans if appropriate)
INSTA1-1 ATIG OF CATCH .
DESCRIPTION OF CONSTRUCTION SEE ATTACHED SKETCH
SEE ATTACHED CONDITIONS
I
DIMENSION OF INSTALLATION OR REMOVAL'
* SEE CONDITIONS R48 6 R49
i
SIZE OF; EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN -A-GAR
APPROXIMATE TIME OF COMPLETION 39913
j 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 th permit and all plicable rules an regulatign�oft `typf�sl
Le Quinta and to pay for any additional replacement necessary as. the r s I of h' rk' .� CIF (ij
Signature of I gent
.
Sr1TiTNRRfJ CAT.TRr1RNTA GAS CQ P_n_ BOX 793 PAT.M 11FSPRT CA 16-14S-7769
Name of Applicant (please print) Business Address Telephone No.
MArm Cr1NST P_(T_ Rny 783 FAT.M TIFSRRT CA 9796171
Name of Contractor and Job Foreman Business Address Telephone No.
9sg�10 56b
I Contractor's. License No.. City Business License No.
RR.7 TANCF TNS NG 195399rn
Applicant's Insurance Company Policy Number
i
FEES:* Subdivision Improvement Permit —Class I I I
Public improvements: -3.% of estimated construction costs q y
Private improvements: 3% of estimated construction costs f
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $ PERMIT VALIDATION
Permit Fee =a PERMIT NO. lig
Penalty 8_Zf_q f
Cash Deposit -Surety Bond DATE APPROVED
if required EXPIRATION DATE ^7 9i SEE eotib R46
TOTAL: $ Q. DATtTUE
Receipt No. By
Received by Date Administrative Authority
Recorded by TELEPHONE: (619) 564.2246
— - TELEPHONE• (61 91564.2246
t