1380NOTE:
-=-With,-proper validation
this form constitutes an
encrdachment 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
Subdivisionlmprovement Permit-=,Class.IjI
March 10 1992
DATE: � Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Paver 111611 t lde �aro+An,
weight, All AInA lAga1.
DESCRIPTION OF CONSTRUCTION CAP ahnae
DIMENSION OF INSTALLATION OR REMOVAL
v
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
Sketch (attach construction plans if appropriate)
ROUTE: Jefferson at Fred daring
into PGA.
DATE: 3/11 in, 3/11 or 3/12 out
2 trips only.
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $ 1
(Including removal of all obstruction, materials, and debris, backfilling, com-
paction and placing permanent resurfacing and/or replacing improvements)
• r
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. 1 F
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. ,
Signature of Applicant or Agent
Tarmac California _ 75-8267
Name of Applicant (please print) Business Address Telephone No.
P.0. L 14050 Palm Desert CA 92255
Name of Contractor and Job Foreman Business Address Telephone No.
On f ile
Contractor's License No. City Business License No.
On f ile
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 costs 1380.
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by Date
Recorded by
PERMIT VALIDATION
PERMIT NO. 1 -3 R®
DATE APPROVED 3/1n.a7
EXPIRATION DATE 3/12/9
DATE I SU 3/10/92
By
Administrative Authority
TELEPHONE: (619) 564-2246
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