1965-�- 19 1,0,6
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, drive ays, pavements, sidewalks, parking lots, sewers, water mains
ec'
and other like public works improvements in connwith MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
DATE: 11/9/93
LOCATION OF CONS
RUCTION
(Street address or Description of Locati
PURPOSE OF CONSTRUCTION
DESCRNPTION OF CONSTRUCTIpN
DIMENSION OF99' 11"L. 211 OI�f LBSVAL 15
SIZE OF EXCAVATION, IF NEADED
APPROXIMATE TI E w7N FORK WIQL BEGIN
APPROXIMATE TIM F C PLETIO
ESTIMATED CONST TI N COST
(Including removal fall b ruction rr
paction and plac' g permanent res fa
In considerati of the granting o
Indem ify, defend and save the + y,
-Mies, liabilities or loss resulti f
�rrinn ac n
happening o
Notify the Adrpinistrative Authority
Comply wi h/all a�plicable City Ordin
La Quint/and toy for any additioi
SubIvi 'on Improvement Permit — Class I I I
T Mino provement Permit Class IV
(attach construction plans if appropriate)
0 GIN: JEFFERSON & FIESTA
1 D STIN ION: EISENHOWER & WASHINGTON
13'9 W, HA UTE: JEFFERSON TO HWY 111 /
\-FROM4M 111—WASHINGTON AND
CAR
terials, and r , backfi ing, com
ig a r replaci g impro ements)
permit, the appli ant here y agrees to:#
authorized agents, officers, re esentatives and ployees, harmless from and against any and all
a claims or court ction and arising out of la amage perso rnroperty
It'of�any work ndertaken under the pe it granted pursuant to this application.
T
le st twenty-four ( 4) hours in advance the time when work will be started.
rice the terms an conditions of the��p rmit and all applicable rules and regulations of the City of
al re acement net�((essary as the result/of this work.
CONSTRUCTkION, INC.1 15030
Name of Applicant (please pri t)
SAME
Name of Contractor and Job Foreman
ON FILE
Contractor's License No.
ON FILE
Signature of Applicant or Agent
NAVE., FONTANA, CA 92335 (909) 355
Business Address Telephone No.
Business Address Telephone No.
ON FILE
City Business License No.
ON FILE
Applicant's Insurance Company I 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 10.00
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $ 10.00
Receipt No.
Received by Date
Recorded by
1965,
PERMIT VALIDATION
PERMIT NO. 1965
DATE APPROVED 11/8/93
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
TELEPHONE: (619) 564-2246
N
Is
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