1216NOTE:
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
DATE: 9-18-91
LOCATION OF CONSTRUCTION
47-385 VIA KORRN
Subdivision Improvement Permit —Class I
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 DRIVEWAY APPROACH SHALL BE CONSTRUCTED
PER RIV. CO. STD. W
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
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
I
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.
ignature of Ap�qnt 4rAgent
WILMA PACIFIC 2801-towagate rd ste 211 westlake village ca 91361 805— 495-50.10
Name of Applicant (please print) Business Address. Telephone No.
Name of Contractor and Job Foreman Business Address "w Telephone No. '
453787 1730
Conwr's License No. , CityBce se No..ti 020891License
8'
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 $ -7-0 II
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
$ 30
Received by Date
Recorded by
1005'Rjh'M91AL91 i8-9130.00 10
PERMIT VALIDATION
PERMIT NO.�-! to
DATE APPROVED
EXPIRATION DATE' wQAt � 3 1— 9
DATE I SUE
By
U Administrative Authority
TELEPHONE: (619) 564-2246
LI.
,`i
111
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
DATE: 9 / Subdivision Improvement Permit — Class Ill
7 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION — Zn 7� ���� 'y^ �j �`S^p0?BN
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION
Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION Lrf 'Vtt,,.J-v_w P-1 APPfloAr-k si`+A w—
,9
--,9�s'L'cc '/p bt, GO>q�ge ?_W;.�t "',
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
CaItr's� 5-CiJ 0o . ZOi
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 t
Age
1U/To.��inesss �
Telephone � N=ot.%
Name of Applicant (please print) /�J
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 Date
Recorded by
PERMIT VALIDATION
PERMIT NO
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
TELEPHONE: (619) 564.2246
Administrative Authority