1897NOTE: 4 s
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: 9/27/93
LOCATION OF CONSTRUCTION
Subdivision Improvement Permit — Class III
Minor Improvement Permit Class IV
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION MOVe EgniRMAt Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION 623 Scraper
15' Nigh, 11110" Wide, 120,000 lbs ROME: 50thh@ Madison to Washington
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
DATE: 9/28/93
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.
irNA C- gAcey
Signature of Applicant or Agent
Granite Const PO Box 9011 Palm DEsert 775-8302
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman
Contractor's License No.
Business Address
Telephone No.
City Business License No.
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:
10.00
$ 10,00
Receipt No.
Received by Date
1897
PERMIT VALIDATION
PERMIT NO. 1897
DATE APPROVED
9/27/93
EXPIRATION DATE 9/28/93
DATE ISS
UED 9/27/93
By
Administrative Authority
Recorded by 11 TELEPHONE: (619) 564-2246
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