2021NOTE:"'
crt6th proper `validation
(this form constitutes an
encroachment permit
CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
N
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: 12/22/93
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION HOVE EQDIP MT
DESCRIPTION OF CONSTRUCTION TEM DOZER
DIMENSION OF INSTALLATIOROR REMOVAL 141a6vH,
13'x6 W, 117'L
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
Subdivision Improvement Permit — Class III
Minor Improvement Permit Class IV
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:
Sketch (attach construction plans if appropriate)
HAUL ROUTE: AVE 52 AND WASHINGTON
NORTH TO CITY LDUTS
HAUL DATE: 12/22/93
q
L2199!3
By_ l
Indemnify, -defend and save the City, its authorized agents, officers,. representatives and employees, harmless from nd gainst any and all
penalties, liabilities or loss resulting from claims or court action and arising out of an accident, loss or damage to persons or
p g g y g p 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"��esult of this work.
.Signature of fj5plicant or Agent - f
SS wo INC. P.O. BOX 831, CSA, CA 92320 (909) 795-2568
Name of Applicant (please print) Business Address Telephone No.
SAS
Name of Contractor and Job Foreman
ON FILE
Business Address
ON FILE
Telephone No.
Contractor's License No. City Business License No.
ON FM ON FILE
Applicant's Insurance Company Policy Number
s
FEES: Subdivision Improvement Permit —Class 111
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
2421
PERMIT VALIDATION
PERMIT NO. 2021
DATE APPROVED 12/22/93
EXPIRATION DATE 12/22/93
DATE1,9S ED k2/22/93
By
v Administrative Authority
TELEPHONE: (619) 564-2246
Cn
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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, driveways, pavements, sidewalks, parking lots, sewers, water mains
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
�I Subdivision Improvement Permit — Class III
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION abcG`
DIMENSION OF INS ALLATION OR REMOVAL-
1.2---/_ — 141 , `P1 /_17 1 1 X ►A
SIZE OF EXCAVATION, IF NEEDED W
APPROXIMATE TIME WHEN WORK WILL BEGIN ItJ h=
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $ N {�
(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:
5- � 4
PILoT CA -f kE-_ .u_.,k_�D .
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.
la/
Signature of Applicant or Agent
II ��
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
Contra ctor'slicense No. City Business Lice4sNo.
�I li
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
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $
Receipt No.
Received by Date
Recorded by
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
TELEPHONE: (619) 564-2246
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