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1207NOTE: 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: Minor Improvement Permit Class IV LOCATION OF CONSTRUCTION 3 "� 9� �f3�E(570N (Street address or Description of Location) PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate) DESCRIPTION OF CONSTRUCTION IVE1A.-A)/ iD1�QDACH v,21�/FwAy PjvAL E3E 60A1sTR VC,TE D ACR DIMENSION OF INSTALLATION OR REMOVAL Z& �i/EIZ CotlMry' STO A/D• 2 o 7 1A7'T4G H E'O) SIZE OF EXCAVATION, IF NEEDED APPROXIMATE TIME WHEN WORK WILL BEGIN 9-/D- 9/ APPROXIMATE TIME OF COMPLETION q`/A`"' 9V ESTIMATED CONSTRUCTION COST $ 300.00 (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 resultingfrom claims or court action and arising out of an accident, loss or damage to g y g 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�Agen �UA Z05C- goacc7'/ES .'iVC 72-850 SoMERA Rp YALM PFS�F2T1GA Name of Applicant (please print) Business Address Telephone No. (&II) 3-¢&- zs82_ Name of Contractor and Job Foreman Business Address Telephone No. 535670 1137 Contractor's License No. City Business License No. /1 /6 / #,4,1 in/oy SPA 1 z & 9.59 5" 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 requirdd TOTAL: Receipt No. Received by Recorded by ,Z ©, 00 10,00 $ -30.00 Date �805VRS, O ?jf4l0709-9 0.40 io PERMIT VALIDATION PERMIT NO. /Z,!::,7 DATE APPROVED 9 " 9 ' C71 EXPIRATION DATE /� " 91 DATE ISSUED 7-9-9/ By =�LGd� A-_4� Administrative Authority TELEPHONE: (619) 564-2246 '. ' � p �� F • ` ea .. NOTE: With proper validation this form constitutes an encroachment oermit 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:L Subdivision Improvement Permit —Class II I ! /�i�/� Minor Improvement Permit Class IV LOCATION OF CONSTRUCTION - h 3— S0 (Street address or Description of Location) PURPOSE OF CONSTRUCTION — 7��Ir/� crrveA�� Sketch (attach construction plans if appropriate) DESCRIPTION OF CONSTRUCTIONS 4X& DIMENSION OF INSTALLATION OR REMOVAL `5 SIZE OF EXCAVATION, IF NEEDED 447,0'61— APPROXIMATE TIME WHEN WORK WILL BEGIN —% Gf�S. 2gR' /U APPROXIMATE TIME OF COMPLETION —L415 • Seg -17• 10 /.00 AjV. ESTIMATED CONSTRUCTION COST $ 1 300, 00 (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 lou resulting from claims or court action and arising out of any accident, lou 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 (241 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. Ignature of Applicant or Agent Name of Applicant (please print) Bv Business Address Telephone No. Name of Contractor and Job Foreman Contractor's License No. Business Address Telephone No. City Business License No. APplicarif's Insurance Company Policy Number FEES: Subdivision Improvement Permit —Class ill Public improvements: 3% of estimated construction costs Privite improvements: 3% of estimated construction costs Minor Improvement Permit — Class IV: See attached schedule Inspection Fee $ %i0 ..0 a II Permit Fee 10 , aPERMIT VALIDATION 0 Penalty Cash Deposit -Surety Bond if required TOTAL: $_ 3a arm Receipt No. Received by Date Recorded by PERMIT NO DATE APPROVED - 051-9 — 9 I EXPIRATION DATE - �� CL I DATE ISSUED — aI `"�( —q � By Administrative Authority TELEPHONE: (619) 664-2246