1630NOTE: ,
'With proper validation
this form constitutes an
encroachment permit
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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 Permit— Class III
DATE: December Id, 1992 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION MOye ESUiRMP"t Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION 14G Blade, It' High, Haul Route: Ave. 52 at City Limits
11' Wide. 66,000 The to Washington and North to Tampico
DIMENSION OF INSTALLATION OR REMOVAL cul Date: 12/17/92
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $
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(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: ,
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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 additional replacement necessary as the result of this work.
`+
Signature of Applicant or Agent's ,
CraA to Construction Compaq P.O. Box 9011 Palm D*8ort, CA 92255
Name of Applicant (please print) Business Address Telephone No.
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Name of Contractor and Job Foreman Business Address Telephone No.
On Pile _ On /File
Contractor's License No, City Business License No.
on rile
On Pils
Applicant's Insurance Company Policy Number
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FEES: Subdivision Improvement Permit — Class I II
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.
10000
$ 10.00
Received by Date
PERMIT VALIDATION ✓
PERMIT NO. 1630
DATE APPROVED
EXPIRATION DATE
12/16/92
12/17/92
DATE ISSUED 12/16/92
By�a
Administrative Authority
Recorded by 11 TELEPHONE: (619) 564-2246
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