1355f
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IIT NOTE•'
'r With proper validation.'
this form constitutes an =`. CITY OF LA QUINTA o
encroachment permit , �. r
r_
- 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:_ February 7. 1992
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
Subdivision Improvement Permit — Class II I
Minor Improvement Permit Class IV
PURPOSE OF CONSTRUCTION Move Equipment Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION Kamatsu PC 400
15' high, 11'10" wide, 140,000 lbs Haul Route: Durango &Montezuma to
52 North on Washington to Hwy 111
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
'005M i 7571 p''�07-92 i
0 CA H i TOTAL i 150.Q04
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $
(Including removal of all obstruction, materials, and debris, backfilling, com- haul Date: 2/10/92
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 timwhen 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'A plicant or'Age t. v
Taaw' c 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.
00n File On.File
Contractor's License No. City Business License No.
4 On File On File
Applicant's Insurance Company Policy Number
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FEES: Subdivision Improvement Permit —'Class 111
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.
$
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Received by Date
Recorded by �K '77 OS g $,
PERMIT VALIDATION
PERMIT NO. 1355-
DATE
355-
DATE APPROVED 2/7/92
EXPIRATION DATE 2'/10/92
DATE ISSUED 2/7/92
By
Administrative Authority
TELEPHONE: (619) 564-2246
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