1853w
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
8/25/93
LOCATION OF CONSTRUCTION Seller Pit Road La Quints,
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Move Equipment
DESCRIeTION F�CONSTRUCTION D6 R
12 W, 5 L, all also legal
DIMENSION OF INSTALLATION OR REMOVAL
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:
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.
Subdivision Improvement Permit —Class I I I
Minor Improvement Permit Class IV
Sketch (attach construction plans if appropriate)
ROUTE: Jefferson, 52nd St,
Monroe, 58th & Keller
�- Pit Rd & return
D
AUG 2 5 1993
-.—.-.... • .-
By
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 th//,;,
work.
..:V�a-4
SignaturA'of App icant or Agent
Johnson Machinery 800 E. La Cadena Riverside (909) 686-5971
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No.
City Business License No.
Nationwide Mutual Ins 73—BA506836-0002
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
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No
10.00
$ 10.00
Received by Date
Recorded%by
1853
PERMIT VALIDATION
PERMIT NO. 1853
DATE APPROVED 8/25/93
EXPIRATION DATE 8/25/93
DATE ISS ED /25/93
By
I&A Ah�jn/AQM
Administrative Authority
TELEPHONE: (619) 564-2246
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