1309",4_ 'NOTE:
�#
Witl*cpPoper'validation
. this form constitutes an
encroachment permit
I 'i
CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
0 1
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
December 12, 1991 Subdivision Improvement Permit — Class I I I
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Move equipment Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION Paver 11' — 6' wide Route - 50th between Jefferson and
Breen and white - all else legal. Washington to Washington andswouth'
out of City limits and return 12/12
DIMENSION OF INSTALLATION OR REMOVAL 1 or 12/13 — two trips.
--" Date 12/12 and 12/13.
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $ K
(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
happeningor occurring as a proximate result of an work undertaken under the permit ranted J
9 P Y P g 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
y La Quinta and to pay for any additional replacement necessary as the result of this work.
Signature of Applicant or Agent
Tarmac California 775-8267
Name of Applicant (please print) Business Address Telephone No.
P.O. Box 14050 Palm Desert, CA 92255 r
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 111
Public improvements: 3% of estimated construction costs
�n
7
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $
Permit Fee
20.00
Penalty
Cash Deposit -Surety Bond
if required
20.00
TOTAL: $
Receipt No.
Received by Date
PERMIT VALIDATION
1309 1)
PERMIT NO
DATE APPROVED 12/12/91
EXPIRATION DATE 12/13/91
DATE IS U 12/1 !/91
By
Administrative Authority
Recorded by 11 TELEPHONE: (619) 564-2246
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