1335•� .NOTEc'
With -proper validation
thi0brm 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
DATE: January 17, 1992
LOCATION OF CONSTRUCTION
Subdivision Improvement Permit — Class 111
Minor Improvement Permit Class IV.
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Move Equipment Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION 623 Scraper, 15'6" H Haul Route: Washington & Fred Waring
X 11'10" W. 120,000 -lbs to Washington and La Fonda
DIMENSION OF INSTALLATION OR REMOVAL Haul Date: 1/20/92
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, backfilling, com-
paction and placing permanent resurfacing and/or replacing improvements)
In consideration of the granting of this permit, the applicant hereby agrees to: .
i' '
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.
4 ivo
Signature of Applrcan 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
Contractor's License No.
On File
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
Private improvements: 3% of estimated construction costs 1335
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $
` Permit Fee 10.00
i`
Penalty
Cash Deposit -Surety Bond
if required
'TOTAL: $ 10.00
Receipt No;,
Received by '4. Date
Recorded by
PERMIT VALIDATION
PERMIT NO. 1335
DATE APPROVED 1/17/92'
EXPIRATION DATE 1/20/92
DATE ISSUE 1/17/92
Administrative Authority
;
TELEPHONE: (619) 564-2246
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