1646NOTE:
VJdth proper validation
this'fo"rm constitutes an
encroach ment.permit
CITY OF LA-A2UINTA
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: January.7, 1993
LOCATION OF CONSTRUCTION 53-240 Ave. Herrera
a�
(Street addressor Description of Location)
Subdivision Improvement Permit — Class III
Minor Improvement Permit Class IV
pl IRpngr: nr- C(1NCTRI ICTInKI Driveway Approach Sketch (attach construction Inns if n ro riate)
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL 6' x 20'
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN 1/7/93
APPROXIMATE TIME OF COMPLETION 1/14/93
ESTIMATED CONSTRUCTION COST $ 300.00
(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:
P PP P
Per Riverside.Co. Std. #207 (Attached)
` A
=t "���isWA 10
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.
M,
Comply with all applicable City Ordinances, the terms and conditioC of the p rmit and all applicable rules and regulations of the City of
La Quinta and to pay for any additional replacement necessary as the esult; this work.
Sign-tflre of.Applicant or Agent
David Roos Miller P.O. Bos 722 La Quinta, CA 92253 564-5823
Name of Applicant (please print) Business Address Telephone No.
Pacific Trades
Name of Contractor and Job Foreman Business Address Telephone No.
B425381 1955
Contractor's License No. City Business License No.
State Farm 91082-81 94
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
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $ 20.00
Permit Fee 10.00
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $ 30.00.
Receipt No.
Received by Date
Recorded by
PERMIT VALIDATION
PERMIT NO. 1646
DATE APPROVED 1/7/93
EXPIRATION DATE 1/14/93
DATE ISSUED 1%7/93
By A_
Administrative Authority
TELEPHONE: (619) 564-2246
ri !'
r'
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
DATE: Z Subdivision Improvement Permit — Class III
Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Dq,t v-�-W ('� A'4,P (to 4-,-h
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL_ -L tom, n
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:
Sketch (attach construction plans if appropriate)
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 i vance of the time when work will be started.
Comply with all applicable City Ordinances, the terms and conditions of th permit and all applicable rules and regulations of the City of
La Quinta and to pay for any additional replacement necessary as the re It f t r wlk
e S
J
Signature of pplicant or Agent
Name of Applicant (please print) Business Address Telephone No.
Q
A.-- l P%rcz-S
Name of Contractor and Job Foreman Business Address Telephone No.
(4ZS 3$I
Contractor's License No. City Business License No.
Applicants 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
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $
Receipt No.
Received by Date
Recorded by
11 CFj
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
TELEPHONE: (619) 564-2246