1668NOTE:
—With proper validation
this form cQnsti:ites an
encroachment permit
N
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
2/993Subdivision Improvement Permit— Class III
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 52-130 AV* Cortez
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION PRtVMW APPROAM
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
Sketch (attach construction plans if appropriate)
PB1EI: RIVSRWIDS COU,!>r#.? t 207
f58AS�1�6h'�i�"�3 30.40
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
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 starteI d.
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. r
Signature of Applicant or Agent
PSIS EMSEN BOX 1258 LA QUWA CA 92253 (619) 654-3112
Name of Applicant (please print)
SAM
Business Address
Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
619724
Contractor's License No. City Business License No:
FSS IN$ F 91006 94 81
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Class 111
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.
$ 20.00
10.00
$ 30.00
Received by Date `
PERMIT VALIDATION
PERMIT NO. 1668
DATE APPROVED 2/9/93
EXPIRATION DATE 2/11/93
DAT ISSUED 2%9/93
By �St� -..)
'--Administrative Authority
Recorded by 11 TELEPHONE: (619) 564-2246
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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 III
DATE: ( Minor mprovement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
Sketch (attach construction plans if appropriate)
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION - t� '3
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:
Ct4rd
qVry r
Indemnity, -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 this work.
Signature of Applicant or Agent
se
0
Name of Applicant (please print) Business Address Telephone No.
:!5'6? -t -,e
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No. City Business License No.
rappncanrs Insurance Uompany 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
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED f1
By }
Administrative Authority
TELEPHONE: (619) 564.2246