1384NOTE"
,�Wi'th proper validation
this form constitutes an
encroachment permit
A
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
.. • •,.,. wx.. .,. _ ,...w .. ♦ .,.M;..Ny:.+.+r •.. +.RyH..�,� .. "1....t +P' `Y.r,..•.t�•.�IC.O.X�...K w�1ih.«RJY:4.i++'.,a. .• ..
Subdivision Improvement Permit=�Cla'ss II°I'�' *- •_ .,
. DATE: March 16, 1992 Minor Improvement Permit Class IV '
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
P JRPOSE OF CONSTRUCTION Paver 11'6" wide 8.4,000 lbs. a Sk ch (attach construction plans if appropriate)
all else legal. /
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR RE OVAL
SIZE OF EXCAVATION, IFNEED
APPROXIMATE TIME WHEN VkOPK VVI11_1_ BEGIN _ i ,/ 1I �/ ,.
APPROXIMATE TIME OF COMO ETI
ESTIMATED CONSTRUCTIO'N CO T $
(Including removal of all obst/fuction, ma `e ' nd debrl ackfilling, com-
paction and placing permanent resurfa ' and/or re cing improvements)
In consideration of the grafting of this permi a applicant hereby agrees to: '
Indemnify, -defend and save the City, it uthorized agents, officers, representatives and employees, harmless from and against any and all
penalties, liabilities or loss resultin rom' claims or court action and arising out of any accident, loss or damage to persons or property
r'
happening or occurrin as a pr mate result of any work undertaken under the permit granted pursuant to this applicatio11 n.
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.
Signature of Applicant or Agent
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No. City Business License No.
i
Applicant's Insurance Company
FEES: Subdivision Improvement Permit — Class 111
i
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.
Received by Date
Recorded by
Policy Number
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
i
1 384
DATE ISSUED
By
Administrative Authority
TELEPHONE: (619) 564-2246
.�.
rte.
4f t�vgq l e 3 41 �=tI+O+•4.f�'111
A$ n.a Aa oeH„�a
03ft5S1 311►0 aN lo''DjM
ILVO NOI1YaIdx3 �= 3dlOL
d7AOV"V 3.1b•0041'na4w 11
uuog 1j1,t's Iqep+a V'tt2
0•: IIWb Ba N,fti+d
NCILMC1IVA liWy]j t ��!►w„�
, S ++i upgaatatw
. l� d ��w�,�n0��w1 ,u�•W
1%LQ2 uoc.unrµuw ojt+wlL V Ip
ts+eo ualunaitvao a+tn„q,ty Ip
1� ;ouw,,,raawl ]�;qrd
pans 's33,�
11ownN ���Od
�.t,w7c:•Y� b�eAnt�l 0lugngpr
ON +tu Y7 1 3 4pue+tu03
� 'oM e►+o+leellt.
"Accor n7u,tns uewe�e
aar Cut,ovutuea Lo w,rM
INN pd Iluuq +1++id1 "t'dov 'a
lua6y to tut�l
_ d” i4 e1A3eta.9,y+
N vq �M M w t,aa p SO IV%W ++,t I$ A.WagMv
tm„"41p�If 11 �y .off J
►"� Iw a� w.w M +acral a wor I>i1 �^nry„w
W^'�1 n Nf oWnr +irsvuwiuor Md 441144
"'4�4� •M 01 tu�+M O+u�e4 1MY.�f 11Y ,Apwt wtibl+.own „ew MA ►0 LUNY who
A Wr ,� 4) •1yp�� jN M U* 6m,e oW WWLUe tN41 AO OW40 MO"A � r trtirq� ,� iw�V
M M A+,e fw.we 1w+0 u,fsy MVV Rl'MWAofnw pM LWM,Wv t►u�4o J+t+�uAa et Aar�1+,o +a wul "t url,"
;C1 t�a,6f AUale4 Sun„ade 1433 Yruu+d 94 A 5ufILQA 143 Io 40ltiu+p,tu03 v!
I ."'•.-'Gaul 6uorldu Jaime burAa
fw ►usutut,.d t)vaNQ Due
'I,Ouoa�
7 fl i "QV 'IuCvq p4f Wi�y '4plyyW-M tlf +0 It�aw1v Swpn�
t LS03 N0w(1V1SNo3 a3xvwllsa
NOLL31dw0� i0 3W11 31bNtxCadd�
N1938't"14M �yORA N31IAA 3w11 3.LdrrlxObddr
C3a33N 11'14011VAYOXI 10 HIS
1rA0W3t} WO NOUV11VLSN1 d0 NOc 31M10
OU -0
a �ON
I'f7730
� P•art0 van '--
4awq wu�
NOLL�fla1SN0� d0 35Cdki11l
rveswo� ye .oarael.q .o �r,aa� uuug�
Al *VNOL1,011wNO3 SO NCIUVJCl
LWy� i►+'�►WA4�WI J041� ""—�
11I �'J � 3►►8La� 14MUMp,,Q;31) 40�WAIp�►}5 � 31rq
rte”
DI=1AM 03A ^U4iyoue SlN3W3AQddWI ii0Nlr1 fp,A4 uoamuuaq w gwu,..oua,t, "114 Mono ev1 ,auto v4e
3414 1>1Nwuplf a++«u1A+q tAtMaAIAp 'taro IlLwid �o �fgnq 0a uo'arti+tatvgp 1143 Sad
r
IlN31AIR-7VOWON�) NOI=nuisNQ:) sxwopA Anand
11AUd !!Od "i0llb'011ddd
VIN1110 v1 10 Alli ► "'-ta �•.•o1m�1
UWaMP,M woa0 ,&A
T@ "d S"W LS: z NOW Z6-9T—Z1"W