1213NOTE:
-With proper validation ,
this form constitutes an ' J
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
Subdivision Improvement Permit - Class II I
DATE- Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION to 191 47-295 Via Horon
(Street address or Description of Location)•
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION Driveway approach Driveway approach shall be
constructed per,Riverside County.
Std. No. 207. -
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION; IF NEEDED''
APPROXIMATE,TIME WHEN WORK WILL BEGIN }. 4
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 teems 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 Ap licc nt '
Wilma' Pacific .2801 Townsgate Rd., Suite .211 Westlake Vi'71age, CA 91361,805-495-5010
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman t Business Address _ _ Telephone No.
453787 1730
Contractor's License No.-, - . Cit Business License No.
USFG: 0208914897
i Applicant's Insurance Company Policy Number
- p- �gg -x�•i 10
FEES:- Subdivision Improvement Permit — Class I I I 1 AS S T 1�AL f 30.00
Public improvements: 3%6f.estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee
Permit Fee
Zd
Penalty
Cash Deposit -Surety Bond
if: required
TOTAL: $
Receipt No.
Received by
Date
Recorded by
C
V
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE'- 10 3 (— Ct
DATE AU ED
By
ministrative Authority
TELEPHONE: (619) 564-2246
i
t4 .
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
9 / Subdivision Improvement Permit — Class III
DATE: / Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION — 90J—
(Street
G T
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION
DESCRIPTION OF CONSTRUCTION ��� l'� %% �y
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
Sketch (attach construction plans if appropriate)
DruvrwAi -' TPtLo is ik-
����
FF -12, SIDE- coottj
N6 ,aF'
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 Applic r Ag
-[�1 � % r7).4 ��a�:��I %L • .1,J'O/ Tocv.��J �� E �J auiTe ��� _ R s'" � %'� c/�'
Name of Applicant (please print)'business Aaaress wLs4L014e. 1/4 Telephone No.
91 34
Name of Contractor and Job Foreman Business Address Telephone No.
'Contractor's License No. City Business L"cense No.
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Class I I I
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
Date
PERMIT VALIDATION
PERMIT NO. \ ?_t--.,>
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
TELEPHONE: (619) 564-2246