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1857I NOTE: 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 DATE 8/25/93 Subdivision Improvement Permit — Class III Minor Improvement Permit Class IV LOCATION OF CONSTRUCTION 52-255 Ave Obregon (Street address or Description of Location) PURPOSE OF CONSTRUCTION Driveway Approach Sketch (attach construction plans if appropriate) DESCRIPTION OF CONSTRUCTION DIMENSION OF INSTALLATION OR REMOVAL SIZE OF EXCAVATION, IF NEEDED APPROXIMATE TIME WHEN WORK WILL BEGIN PER RIVERSIDE COUTX STD 0 207 Y V 17;UG 5 1993 APPROXIMATE TIME OF COMPLETION B 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. Signature of Applicant or Agent Dsevi4 Ross Miller PO Mx 722 1A Qninta 342-8363 Name of Applicant (please print) Business Address Telephone No. Pacidid 'Trades Dev Name of Contractor and Job Foreman Business Address Telephone No. On File On Bile Contractor's License No. City Business License No. On Bile 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 $ 20.00 II Permit Fee Penalty Cash Deposit -Surety Bond if required TOTAL: Receipt No. 10.80 $ 30.00 Received by Date 1857 PERMIT VALIDATION PERMIT N0. 1857 DATE APPROVED 8/25/93 EXPIRATION DATE 8/30/93 DATE ISSU -El,j ,�� �-`8/25//�93 By fy�lYl, Zil�.c,L.�.0 Administrative Authority Recorded by 11 TELEPHONE: (619) 564-2246 NOTE: , ti 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 lou, sewers, water mains and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS GATE: Subdivision Improvement Permit — Class III LOCATION OF CONSTRUCTION � o Minor Improvement Permit Class IV S 7- 2 s s A.) dS� L 6 0 rJ (Street address or Oeseription of Location► PURPOSE OF CONSTRUCTION D2 \ cit w �,� A 0 V li-w Sketch (attach construction plans if appropriate) DESCRIPTION OF CONSTRUCTION C', o, DIMENSION OF INSTALLATION OR REMOVAL— SIZE OF EXCAVATION, IF NEEDED APPROXIMATE TIME WHEN WORK WILL BEGIN APPROXIMATE TIME OF COMPLETION 45 21 ESTIMATED CONSTRUCTION COST S -- (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 emp,OVM. 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 undwUlcen 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. Colmply with all apPIkable Citv Ordinances. the terms and eonditioAI of the permit and all applicable rules and La Quints and to pay for any additional replacement n \ regulations of the City of eoessary es the n It of C� \ a VAN Signature of Pplicant or Agent o. z 1- - 4 L_ ta� .2- �s3so Name of Applicant (please print) Business Address 4 3 Telephone No. -t\ t2,, '1Z \ c- -ma >a-,5 b t.J• Sart SAv�� Name of Contractor and Job Foreman Business Address Telephone No. L'->yZS3%sl �(ZL5(r Contractor's License No. City Business License No. != A2`ck t _c,QS, F `t to%?— 9,I � 7 Applicants Insurance Company Policy Number FEES: Subolvislon Improvement Permit —Class I11 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 By TELEPHONE: (619) 564.2246 Administrative Authority