1631NOTE
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
DATE: Z� 12-1&-92 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 77$00 Madrid
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION4r1"e*Ay 422ro"11
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN 12-18-92
Sketch (attach construction plans if appropriate)
per Werside Co. $td #.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
C" happening or occurring as a proximate result of any work undertaken under the permit granted pursuant to this application.
q� Notify the Administrative Authority at least twenty-four (24) hours in advance of the time when work will be started.
p. Comply with all applicable City Ordinances, the terms and conditions of the,per it and all applicable rules and regulations of the City of
La Quinta and to pay' for any additional replacement necessary as the resul of thisAwark.
Sig re of Ap6rcant or Agent
p Jack Cloyton 52920 V*1100 1.a Quinta $64-4537
Name of Applicant (please print) Business Address Telephone No.
Irl
O,�raez/6ulildet� .
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No.
State ram
City Business License No.
5�MJ6--247-�
Applicant's Insurance -Company Policy Number
FEES: Subdivision Improvement Permit — Class I I I
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
l Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No
Received by
Recorded by
$ 20
10
$ 30
Date
0031 io
30-00
PERMIT VALIDATION
PERMIT NO. 1691
DATE APPROVED 12-18-92
EXPIRATION DATE 12-24-92
r
DATE ISSUED it 12 18-92
By
V `Administrative Authority
TELEPHONE: (619) 564-2246
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 II I
DATEI'd .�_(1 j f(�li Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION %% i101/ e2&1bl2f
(Street address or Description of Location) ` J
PURPOSE OF CONSTRUCTION ���� ✓ew(+ 7 Sketch (attach constructionlaps if appropriate)
ppropriate)
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGI
APPROXIMATE TIME OF COMPLETIgaterials,
/Z 5Z
ESTIMATED CONSTRUCTION COST
(Including removal of all obstruction, 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 additional replacement necessary as the result of this work.
Signature of Applicant or Agent
J./{ -C C
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
License No.
licant's Insurance Com
City Business License No.
4: . �/ Policy Number $`57"T
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
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $
Receipt No.
Received by Date
Recorded by
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
TELEPHONE: (619) 564-2246