1408NOTE:
' 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
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Subdivision Improvement Per'_mit "Class-l°I:L-,: > ..� �
DATE: 4-2-92 Minor Improvement Permit Class IV
53-385 Diaz
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Install driveway approach Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN 4-3-92
Per riverside Co. std No. 207
(attached)
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 applicable rules and regul�'�s- f the City of
La Quinta and to pay for any additional replacement necessary as the result of thi oak.
Signature of Applic to gent
Gregg Barman 76-518 Daffadil Dr. Palm Desert,.CA 92Z
Name of Applicant (please print)
Business Address
Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
621112 0081 t
;xti 4
Contractor's License•No. City Business, License No:y.«1 `•"-
State Fund 1270097 --Ir
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Class 111 0ouer` CASN8�8T8TAL2i9130.OQ
Inspectio
Permit F
Penalty
Cash De
if require
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: Se attached schedule
n Fee $
ee 10
j
Dep
Bond
d
TOTAL: $ 30
Receipt No.
Received by Date
tf
Recorded by
1408
PERMIT VALIDATION
1408
PERMIT NO.
DATE APPROVED 4-2-92
EXPIRATION DATE 4-10-92
DATE ISSUED —2-92
By
Administrative Authority
TELEPHONE: (619) 564-2246
e
-----------------------------------------------------------------------------------------------
----------- -------- ------------
NOTE:
With proper validation
this form constitutes an CITY OF LA QUINTA
encroachment permit
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:�—
LOCATION OF CONSTRUCTION
Subdivision Improvement Permit —Class III
0 -Minor Improvement Permit Class IV
a -2,
(Street address or Description of Location) r ,
PURPOSE O=N',CTION
Sketch (attach construction plans if appropriate) c
DESCRIPTIO 'OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
f
1
APPROXIMATE TIME OF COMPLETION/ S"Z�
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 Quints and to pay for any additional replacement necessary as the result of this work.
of Applicant (please
Signature of Appl
Business Address
or
Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
4""20
Contractor's License No. City Business License No.
'JE�
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit —Class III
FIMPIR
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs 1236
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $ Z� II PERMIT VALIDATION
Permit Fee
Penalty .
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.--•:.
!o
$ 3�
Received by Date
Recorded by
PERMIT NO. /_q/0J9
DATE APPROVED
02
EXPIRATION DATE 0
DATE ISSUED
By µ
Administrative Authority,.
TELEPHONE: (619) 564-2246