1941NOTE:
With proper validation
this formconstitutes 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
Subdivision Improvement Permit — Class I I I
DATE: 10-22-93 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 51-505 Avenida MArtinea f,
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Conatruct Stucco Wall Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REM,0VAL
SIZE OF EXCAVATION, IF NEEDED % 2'
APPROXIMATE TIME WHEN WORK WILL BEGIN av-cc—yam
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION CONSTRUCTION COST $
(Including removal of all obstruction, materials, k 'I terials, and debris, bacing, co
paction.-and placing permanent resurfacIi4 g. and/or replacing improve ent )
In consideration of the granting of this perm the applicant hereby agar R
es tto:
Indemnify, -defend and save the City, its authorized nts, officers, represenes
penalties, liabilities or loss resulting from claims or Cour action and arising of
happening or occurring as a proximate result of any work un rtaken under the per
Notify the Administrative Authority at least twenty-four (24) hour 'n advance of t
Comply with all applicable City Ordinances, the/berms—a,pd conditions o e permit
La Quinta and to pay for any additional repJ6cement nece\ssaf�y_ as the result this
emplo ees, harmless from and against any and all
V acci ent, loss or damage to persons or property
: grant d pursuant to this application.
time hen work will be started.
J all applicable rules and regulations of the City of
)rk.
J.0\B01504
Sign ture of Ap licant or Agent
Danny• Johnson
La
inta CA 92 53 777-7052
Name of Applicant (please print
A
Business A • ress Telephone No.
Owner; Builder
f.
Name of Contractor and Job Foreman
Business Addre
s Telephone No.
Contractor's License No.
City Business License No.
Applicant's Insurance Company
P Iicy.Number
FEES: Subdivision Improvement Permit — Class I II X,,�--
Public improveme 39la.ofi esti�wate' construction costs
Private im ovements: 3% of estimated construction
costs
Minor Improvement Permit — Class IV: See attached schedule 1.941
Inspection Fee $
PERMIT VALIDATION
Permit Fee
r
PERMI NO. ! 1941
Penalty
Cash Deposit -Surety Bond
DATE APPROVE 10-22-93
if required
EXPIRATION DATE
TOTAL: $
DATE ISSUED
Receipt No.
By
Received by Date
Administrative Authority
)Recorded by
TELEPHONE: (619) 564-2246