1301NOTE:
__ With proper validation- _
this.fofm.constitut.1 an., I CITY OF LA QUINTA
- enci`oachment permit ,/
~�- APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
0
J
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
'November. 26, 1991
Subdivision Improvement Permit — Class I I
Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION '
G
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Move Equipment Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION Grinder — 10' wide, HAUL ROUTE: Washington Street to
84,000 lbs. — all else legal. Ave 52 to Bermudas. _
DIMENSION OF INSTALLATION OR REMOVAL Haul date: 11/27/91.
} SIZE OF EXCAVATION, IF NEEDED
1
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
I 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 works c f�
Signature of Applicant or Agent
Tarmac California P.O. Box 14050 Palm Desert, CA 92255 775-8267 y
Name of Applicant (please print) Business Address Telephone No.
I
Name of Contractor and Job Foreman Business AddressTelephone No.
On File On File
Contractor's License No. City Business License No.
On File On File
Applicant's Insurance Company f Policy Number
FEES: Subdivision.lmprovement 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 $ 10
Permit Fee 10.00
Penalty
Cash Deposit -Surety Bond
if required
TOTAL
Receipt No.
$ 10.00
Received by Date
Recorded by
13 011
PERMIT VALIDATION
PERMIT NO. 1301
DATE APPROVED 11/26/91
EXPIRATION DATE
11/27/91
11/26/91
DATE# I ,
By
Administrative Authority �
TELEPHONE: (619) 564-2246
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