1957Fv'OTE:
'With proper validation
tqiis 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
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DATE: 11/5/93
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION NODS EQ
UIPMM
DESCRIPTION OF CONSTRUCTION 8250 TEREY DOZER
DIMENSION OF IN�TAI LATION OR REMOVAL 14'3'*B, 14.6"9,
---w L, 232,000 LBS
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
Subdivision Improvement Permit — Class I I I
Minor Improvement Permit Class IV
11
Sketch (attach construction plans if appropriate)
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:
HAUL ROUTE: WASHINGTON FM
HWY 111 TO LA FONDA
HAUL DATE% •11/5/93
PILOT CAR
L, .
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 wo
a`
Sjo'
nat e of Applicant or Agent
DALTON TRUCKING 13560 WRI1TRAM, FONTANA, CA 92335 (909) 283-0663
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
ON YM ON FILE
Contractor's License No. City Business License No.
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ON FILE ON FM
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 $
Permit Fee 10.00
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $ 10.00
Receipt No.
Received by Date
Recorded by
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PERMIT NO.
PERMIT VALIDATION
1957
DATE APPROVED 11/5/93
s. EXPIRATION DATE 11/5/93
DATE ISS ED 110193
By W I W� dX_W�_
Administrative Authority
TELEPHONE: (619) 564-2246
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