1732JT
`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: 5/6/93 MinorImprovementPermit Class IV
-LOCATION OF CONSTRUCTION Ave 58
I" •
(Street address.oe Description of Location)
' ;PURPOSE OF CONSTRUCTION Move EquipmentSketch .(attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION On. Ave 58 from County. Road to
!l; Quarry Project
DIMENSION OF INSTALLATION OR REMOVALI5'6"High, 14�
Wide, 115,000#'
SIZ1. E 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- ,A i
paction and. placing permanent resurfacing and/or replacing improvements) ►'�D� �n ��u'�
I
I'm consideration of the granting of this permit, the applicant hereby agrees to: ! ,
fIndemnify, 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.
f
[, Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules and regulations of the City of
i La Quinta and to pay for any additional replacement necessary as the result of .this work.
ignature •` JJ5�ica or Agent
,James E Simon Co PO -Box 10990 Indio 92200 .':347-5399
Name,of Applicant (please print) Business Address r Telephone No.
Name of .Contractor and Job Foreman Business Address Telephone.No.
521795 1217 }
Contract'or's License No. City Business License No.
t..
On File On File
Applicant's 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 .VALIDATION`
Permit Fee 10.00 1732 .
• PERMIT"N O.
Penalty ,
Cash Deposit -Surety Bond
if required
:•TOTAL: $' 10.00
Receipt.:No. '
`Received by Date
•Recorded by
DATE APPROVED 5/6/93.:, r ,
N
EXPIRATION DATE 5/•6/93
DATE'IS'IED 5/61"
jrr
By. j
Administrative Authority
TELEPHONE; (619) 5642246
(Bill '1"
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