1344NOTE:
?46 proper validation
this form constitutes an
encroachment permit
36
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I
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
Subdivision Improvement Permit— Class III
DATE: January 27. 1992. Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION' _
(Street address or Description of Location)
- r
PURPOSE OF CONSTRUCTION Move Equipment Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION __Paver, 11'6" wide. green Haul'Route: Jefferson at Fred Waring
weight. All else legal to PGA
DIMENSION OF INSTALLATION OR REMOVAL Haul Date: 1/27/92"-_
1
SIZE OF -EXCAVATION, IF NEEDED ,
APPROXIMATE TIME WHEN WORK WILL,BEGIN
APPROXIMATE TIME OF COMPLETION o {
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 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., w
Signature of Ap�14nt or 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. 77
On File On File
Contractor's License No.' - City Business License No.
On File On File
Applicant's Insurance Company t 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 ,.
Inspection Fee
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required _.
TOTAL:,
Receipt No.
10.00'
,
$ 10.00
Received by Date
Recorded by ;
PERMIT VALIDATION
PERMIT NO. 1344
DATE APPROVED 1/27/92
EXPIRATION DATE 1/27/92
DATE ISSUED
By
Administrative Authority
TELEPHONE: (619) 564-2246
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