1533NOTE: _
With proper validation
_,this form constitutes an
encrobachmeit',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
DATE: September 3, 1992
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION MOVQ Equipment
DESCRIPTION OF CONSTRUCTION Orinder 10' tide.
84,000 1be. ,
DIMENSION OF INSTALLATIOROR REMOVAL
/`
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
Subdivision Improvement Permit — Class II I
Minor Improvement Permit Class IV
Sketch (attach construction plans if appropriate)
ROMEs Ave 52 at City Limits to
Vashington to Tampico to Paloma.
PATEs 9/3/92
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
e
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 additional replacement necessary as the result of this work.
%Ln
Signature of Applicant or Agent
Granite Const. Co. P.O. Bat 9011 Prlr► nopmrr 9 f�A :0774K 124-8102
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
On file
Contractor's License No. City Business License No.
Applicant's Insurance Company 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 10.00
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No
Received by
Recorded by
$ 10.00
Date
PERMIT VALIDATION tom.
PERMIT NO. 1533
*4 DATE APPROVED
9/3/92
EXPIRATION DATE 9/3/92
DATE ISSUED ,3
/92
By
TELEPHONE:
f Administrative Authority
6i`
( 1 564-2246