1397V.4
c. _.NOTE:
`With'pro.per validation r� 2•
tA' histfo'rm constitutes an
encroachment permit CITY OF LA�°�QUINTA
w _ - 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
March 24, 1992 Subdivision Improvement Permit —Class I II
DATE: I Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Move, Loader
DESCRIPTION OF CONSTRUCTION Legal wt t engt
Sketch (attach construction plans if appropriate)
ROUTE: MILES AVE. TO JEFFERSON
TO AVE 52 TO MADISON AVE.
DIMENSION OF INSTALLATION OR REMOVAL 1101 vaidth
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
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 additionalreplacement !necessary as the result f 'is ork.
Si t Applicant or gent
F.J. Stowells P.O. BWM 105 Ind o, CA 774=1359
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
PVC 105959
Contractor's,License No. City Business License No.
Cal Farm
s'
Applicant's Insurance Company Policy Number
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 10.00
Penalty
Cash Deposit -Surety Bond
if required
10.00
TOTAL: $
Receipt No.
Received by Date
Recorded by
M1111 �AOSH S1 `TOTAL` i 92 6. O00
1.�9Z
PERMIT VALIDATION -
PERMIT NO. 1397
DATE APPROVED _3/24/92
EXPIRATION DATE N3/24/92
DATE ISSUED '3/21/92
By
- Administrative Authority
TELEPHONE: (619) 564-2246
• S
V
�
.l
NOTE:
With proper validation
this form constitutes an
encroachment 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
Subdivision Improvement Permit -Class III
DgTE:- /44, _ Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION 6CCfP --mss
DESCRIPTION OF CONSTRUCTION L 4_ l.N
DIMENSION OF INSTALLATION OR REMOVAL - '-
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN 6
APPROXIMATE TIME OF COMPLETION /9/9
ESTIMATED CONSTRUCTION COST $ �� f
(Including removal of all obstruction, materials, and debris, backfilling, com-
paction and placing permanent resurfacing and/or replacing improvements)
Sketch (attach construction plans if appropriate)
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
ivame or mppucant kpiease print)
Business Address
Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
',��
Contractor's License No.
City Business License No.
Applicant's Insurance Company I 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 1 V
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $
Receipt No.
Received by .,Date
Recorded by
1236
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE 3 - 2 -
DATE
DATE ISSUED 2 -
By By
Administrative Authority
TELEPHONE:. (619) 564-2246