1308• � NOTE:'
With proper validation,
T..._ _—this form constitutes an CITY OF LA., QUINTA '
_.+ "encroachment permit
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
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For the construction bf 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: December 12, 1991
LOCATION OF CONSTRUCTION Move equipment
Subdivision Improvement Permit — Class I I I
Minor Improvement Permit Class IV
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(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Move equipment Sketch (attach construction plans if appropriate)
• DESCRIPTION OF CONSTRUCTION Paver 11' — 6 wide,
green wt, -all else legal. Route 50th between Jefferson and
,Washington, to Washington and,
DIMENSION OF INSTALLATION OR REMOVAL out of City limits and return 12/12
or 12/13 - two trips.
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SIZE OF EXCAVATION, IF NEEDED- ..Date 12/12/ and 12/13.'
APPROXIMATE TIME WHEN WORK WILL BEGIN. Ilk
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 improvement )
In consideration of the granting of this permit, the applicant hereby agrees to:
,.�
Indemnify, -defend and save the City, its authorized agents, officers, repr ntati and emplo ees, harmless from and against'any and all
penalties, liabilities or loss resulting from claims or court actio an, arisin out f any
g teacci ent, loss or damage to persons or property
happening or occurring as a proximate result of any wo un rtaken rider the mit d pursu t to this applicatio
Notify the Administrative Authority at least twenty-four (24) hours in dvanc of t e time wh work will beistarteedd.
Comply with all applicable City Ordinances, the terms an c n ' ions o the permit and �a pplic "le rules arV`kreguf�f'lO of the.City of
La Quinta and,to�pay for any additional replacem nt nec ss ry as -the esult of this U
Si ture of Applicant or Agent
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Tarmac California 775-8267
Name of Applicant (please printBusiness Address _Telephone No.
P.O. Box 14050' Palm Desert, CA ,,gn'60
Name of Contractor and Job Foreman Business Address Telephone No. ,
On file On file
Contractor's License No. City Business License No.
On file
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' « r
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Inspection Fee $.00 II PERMIT VALIDATION
Permit Fee 1'308
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $ 0"•00
Receipt No
Received by
Recorded by
Date
PERMIT NO.
DATE APPROVED 12//12/91
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
TELEPHONE: (619) 564-2246
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