1269NOTE:
✓With proper validation 2
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 II
DATE:_ October 30, 1991 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION Grinder. 101 wide. All
else legal
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
Haul Route: Washington and La Fonda
to 52 to City Limits
Haul Date: 10/31/91
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:
j
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 or Agent
Tarmac California P.O. Box 14050 Palm Desert, CA 92255 775-8267
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address , Telephone No.
On File On File
Contractor's License No. City Business License No.
On File On File
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 1 269, -
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. 1269
DATE APPROVED 10/30/91
EXPIRATION DATE
10/31/91
DAT SUED 10/30/91
By
' Administrative Authority
TELEPHONE: (619) 564-2246
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CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUC'T'ION
(ENCROACHMENT)
For rna
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PROVE[)
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PURPOSE OF C0?4SMUC-non
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DIMENSION OF on INSTALLATION
LLA n, REMOVAL
SIZE OF EXCAVATION. IF NEEDCO
APPROXIMATE 'rImE
WORK %ILL BEGIN
APPROXIMIATE TIME OF COUPLE'TION
ESTIMATED CONSTRUcMON COST j
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TOTAL:
AwMal No.
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Policy Iyurn
PERMIT VALIDATION
HERMIT %o.
DATE APpROVEt)
EXPIRATION DATE
DATE ISMED
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