1654NOTE..`"—"r"'� ..�,w..
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
1/2293 Subdivision Improvement Permit — Class III
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION WASHINGTON S/0 SIMON
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
ROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $
(Including removal of all obstruction, materials, and debris, backfilling, com-
action and lacin ermanent resurfacin and/or re lacin im rovements)
Sketch (attach construction plans if appropriate)
TRANSPORT KOMA TSU BLADE
DIMENSIONS: 10'W -1412H -65'L
WEIGHT 100,000(1
FROM WASHINGTON @ SIMON TO NORTH
CITY LIMITS OVER WASHINGTON
p 1 p g p g p g p
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 propeety
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
CATTRAC CONSTRUCTION 15030 SLOVER AVE FONTANA CA 92335 (909) 355-1116
Name of Applicant (please print) Business Address Telephone No. J.
CRIST EXCAVATION & GRADING (909) 733-3120
Name of Contractor and Job,F,.oreman Business Address " "" Telephone No.
Contractor's License No. City Business License No.
GOLDEN EAGLE INSURANCE CCP194870
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 $
Ov
Permit Fee ) j n
Penalty
Cash Deposit -Surety Bond
if required ``
TOTAL:
Receipt No
Received by Date
Recorded by
1f �4
PERMIT VALIDATION
PERMIT NO. �'s Lj
DATE APPROVED a C3
EXPIRATION DATE
DATE ISSUED
By �k�
11 Administrative Authority
TELEPHONE: (619) 564-2246