1306jWith,proper validation
this form constitutes an " f o •-'' `R '
CITY OF L'A;POUINTA .
,encroachment permit - • � . � �
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
c�y r
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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
f F Subdivision Improvement Permit— Class III
DATE;.. December 5, 1991 Minor Improvement Permit Class IV
r"
I LOCATION OF CONSTRUCTION
(Street address or Description of Location) '
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate) . .
DESCRIPTION OF CONSTRUCTION Barber `Creena •11'6" wide.
Green Weight, All Else Legal Haul Route: -Washington at Fred
Waring to 50th and East to .job site
DIMENSION OF INSTALLATION OR REMOVAL
Haul late: 12/6J91
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,'backfill ing, com i' t
paction and placing°permanent resurfacing,, and/or replacing improvements) a
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.
PNotify 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.
-moi QL aA6,ty
,t s Si6nature'of Applic�a,t r,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 III
Public improvements: 3% of estimated construction costs
G Private improvements: 3% of estimated construction costs 1306
G Minor Improvement Permit — Class IV: See attached schedule ,
Inspection Fee $ PERMIT VALIDATION
Permit Fee 10.00 PERMIT N0. 1306
Penalty
Cash Deposit Surety Bond DATE APPROVED 12/5/91
1 if required EXPIRATION DATE 1216/91
TOTAL: $ 10.00 DATE ISSUED W5191
Receipt No. N�� N��
By
Received by Date Administrative Authority
.Recorded by TELEPHONE: (619) 564-2246
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