1341NC`fE r•� " r /.
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With proper•validation
this form constitutes an CITY OF LA QUINTA �
encroach ment,permit
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
• Cit+, FS
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
Subdivision Improvement Permit — Class III
DATE: January 22, 1992 Minor Improvement Permit Class IV �
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Pfiave Equipment Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION 623 Scraper, 1516" Xi)xh, Haul Routes La Fonda 6 Washington to
11110"'wide. 120.000 lbs 1152'& East to Citq Limits
DIMENSION'OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION,,IF NEEDED
Haul Datev 1/23/92
APPROXIMATE TIME WHEN.WORK.WILL BEGIN '
APPROXIMATE TIME OF COMPLETION *f1-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 kand-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. '
F
+ Signature of App hc a t or Agent
Tarmac California P.O. Box .14050 Palm Desert, CA 92255 715-8267
Name of Applicant (please print)' Business Address Telephone No.
Same
Name of Contractor and Job Foreman Business Address Telephone No.
On Bile 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 I I I
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costsr4•
�, �*• .
Minor Improvement Permit —.Class IV. See attached schedule
Inspection Fee $
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
10.00
$ 10.00
s
Receipt,No.
Received by Date
Recorded by
PERMIT VALIDATION
PERMIT NO
DATE APPROVED
1341
1/22/92
EXPIRATION DATE 1/23/9
DATE ISSUED 1/aR/92
By
4;;
Administrative Authority
TELEPHONE: (619)4-2246
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