1856NOTE:'
With proper validation
this form constitutes an� CITY OF LA QUINTA
encroachment permit
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
8/25/93 Subdivision Improvement Permit — Class III
'DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION TM
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION M*V'e Equipment
DESCRIPTION OF CONSTRUCTION 824 Dozer
13' H, 1319" W, 67,000 The
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
Sketch (attach construction plans if appropriate)
ROUTES
DATE: "wW91P•
PILOT CAR REQUIRED
APPROXIMATE TIME WHEN WORK WILL BEGIN Jeffezeon, Ave 54,
Madison, Acre 58
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 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.
44
Signature of Applicant or Agent
w
Picoui Trucking
Name of Applicant (please print) Business Address Telephone No.
Nuevo Engineering
Name of Contractor and Job Foreman Business Address Telephone No.
Ou File
Contractor's License No.
On f ile
City Business License N
n 444
tt
On File On File
01 LU rr
Ap`'p`licant's Insurance Company Policy Number
t �,J^
FEES: Subdivision Improvement Permit —Class III 4
Public improvements: 3% of estimated construction costs 3 Private improvements: improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule 1 856
Inspection Fee $ PERMIT VALIDATION
Permit Fee 10'00 PERMIT NO. 1856
Penalty
DATE APPROVED 8/25/93
Cash Deposit -Surety Bond
if required EXPIRATION DATE ��' rJ /� %�,�
TOTAL: $ 10.00 8/25/93
DATE ED
Receipt No. 5
By
Received by Date Administrative Authority
Recorded by 11 TELEPHONE: (619) 564-2246
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