1214NOTE:
With proper validation 4 2
O
this form constitutes an CITY OF LA QUINTA
encroachmentP ermit
APPLICATION FOR PERMIT _ f�
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: '9-18-91
LOCATION OF CONSTRUCTION
47-325 via koron
Subdivision Improvement Permit — Class III
Minor Improvement Permit Class IV
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION DRIVEWAY APPROACH Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
DRIVEWAY APPROACH SHALL BE CONSTRUCTED
PER RIV. CO. STD. 207
* note: THE SECTION OF ASPHALT CONCRETE
AND BASE TO BE REMOYEDDSHALL BE REPLACED
WITH A DEEP STRENGTH LIFT OF ASPHALT
CONCRETE AND COMPACTED TO 95% RELALive
COMPACTION MINIMUM.
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 a-nd 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 Appli�peor ent
WILMA PACIFIC 2801 TOWNGATE RD STE 211 WESTLAKE VILLAGE CA 4661 803-495-5010
Name of Applicant ('please print) Business Address Telephone No.
a �
Name of Contractor and Job Foreman Business Address Telephone No.
453587 11730
Contractor's License No. City Business•License No.
usfg . 0208914897
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Per — Class I I1 1�051C842S Of 4�0PA 49i ""N.00 10
Public improvements: 3% of estimated construction, costs V 1 �,• r 1
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.
$ 20
AD
Received by Date
PERMIT VALIDATION
PERMIT NO. Z• I Ll
DATE APPROVED
EXPIRATION DATE
DATE ISSUED V
By
I Xdministrative Authority
Recorded by 11 TELEPHONE: (619) 564-2246
r
ra.
r
NOTE: A
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
y
i / y / Subdivision Improvement Permit — Class I I I
DATE. Minor Improvements Permit Class IV
LOCATION OF CONSTRUCTION — A0 `7" / 9 , %!'7- • %�� �i A /' ot�a .✓
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION ��%vim �> 9i �kv�a'( ��` ,
DIMENSION OF INSTALLATION O REMOVAL c `7u�l S�ic> v -a z.�P-7
!3 �% r.i�c /� /� ✓ f� fr . G7�JD, .z ccJ
SIZE OF EXCAVATION, IF NEEDED -r�� c��C.T1G,a ASpiiALT Cv0 fe
APPROXIMATE TIME WHEN WORK WILL BEGINLA�E.� �TRC,,�c,'Gt+
LIFT OF q��ig1_T RN�.
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $
(Including removal of all obstruction, materials, and debris, .backfill ing, 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.
Name of Applicant (please print)
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No. City Business License No.
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit —Class III
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,
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
TELEPHONE: (619) 564-2246
Administrative Authority