1875NOTE:
`With proper validation
'this form constitutes an
encroachment permit
CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
w 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: 9-893
r LOCATION OF CONSTRUCTION 53-605
1
Ramirez
Subdivision Improvement Permit— Class III
Minor Improvement Permit Class IV
i( (Street address or Description of Location)
driveway approach
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)
t
I DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
,r
APPROXIMATE TIME WHEN WORK WILL BEGIN "-93
per Riverside Co. Std 207
APPROXIMATE TIME OF COMPLETION 9-10•-93
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.
00. AP&4
Signature o�Applicant or Agent
Belknap conatrtutioo P.O.Sox 207 Palm Desert CA 92261 564-2783
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
652815 .2845
1'
City Business License No.
1344682-93
Contractor's License No.
State P=d
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
20
Inspection Fee $
Permit Fee 10
Penalty
Cash Deposit -Surety Bond
if required .
TOTAL:
Receipt No.
Received by
Recorded by
$ 30
Date
SEP 0 8 1993 L
$75 By b
PERMIT ,VALIDATION
PERMIT NO. 1875
DATE APPROVED 9-8-93
9-10-93
EXPIRATION DATE
DATE ISSU D
By
.� Administrative Authority
TELEPHONE: (619) 564-2246
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 rcairo
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
DATE:_8 PaL
Subdivision Improvement Permit — Class 111
Minor Improvement Permit Class IV
LOCATION OF CO STRUCTION -- 53 - i,05 ��' ,�,,Q�
(Street address or Oesertption of Location)
PURPOSE OF CONSTRUCTION
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION xg
ESTIMATED CONSTRUCTION COST S
(Including removal of all obstruction, materials, and debris, backfilling, cam
pwtion and placing permanent resurfacing and/or replacing improvements)
In consideration of the granting of this permit, the applicant hereby agrees to:
Sketch (attach construction plans if appropriate)
penalties,
defend and save the City, its clamm"d agents, officers, reprasentatim and employees. harmless from and against any and all
happening
liabo=u or loft relaxing from daYtq or court action and arising out of any aCCident, lots or
dame"happenuq or ooeumnq as a pr07tirgte re'eult of any woftc undertaken under the to this to lanae Or property
Wrrttit grsnted pursuant to this alWitatiat.
Notify the Administrative Authority at wast twenty-four 1241 hours in advance of the time when wort will be started,
Compal with all applicable City Ordinarws. the tamand conditions of the permit and all applicable rule and regulations of the City of
La Ouinta and to pay for any additional replacarnant neoasory u tha�zlult of this _worh.
^ l Lp,zi9hatyjP,6f Applicant or Agent /
�XJ A0520—+ t9 9 -W-Name of A plicant (please L0_J&_,r.29
print) Business Address
Telephone No.
Name of Contractor and Job Foreman Business Address
5 a8 /_3 Telephone No.
Contractor's License No.
Applicant's Insurance Company
City Business License No.
'3gq(�,0O-93
Policy Number
FEES: Subaivision 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.
a
$
Received by Date
Recorded by
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
TELEPHONE: (619) 564-2246
Administrative Authority
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