2022lti
NOTE%
With prWer validation
'this form constitutes an
encroachment permit
I
CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
J'r
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 II
DATE: 12/22/93 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION � - STMT AT BIBS
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION
DESCRIPTION OF CONSTRUCTION IBSTALL WATM MAIK
IN WASHING= STBBBT
DIMEjWN OF INSTALLATION OR REMOVAL
I».F. OF QAM M=V
1
SIZE OF EXCAVATION, IF NEEDED LY loo's
101MG1
APPROXIMATE TIME WHEN WORK WILL BEGIN A8AP
Sketch (attach construction plans if appropriate)
MM ATTACKED COHDMONS
SBS AITAC BD DRAW=
' f
APPROXIMATE TIME OF COMPLETION " . I By
ESTIMATED CONSTRUCTION COST $ '101000.00
(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:
L-\ D
JAN 0 r 1994 DI
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.
Signature of Applicant or Agent
T.D. DES= MMMAPKW P.O. DU 1716, 1A QVINTA, CA
Name of of Applicant (please print) Business Address Telephone No.
MOM G ASSOCUM, HAY BAHZ= 'P.O. S(M 1135. LA QUM&, CA 564-3535
Name of Contractor and Job Foreman Business Address Telephone No.
654
Contractor's License No. City Business License No.
AIM LM i CASMTi � 86=22703025 i PW206704 00
Applicant's Insurance Company Policy Number
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 7 $ 100.00
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
>tn.0)
a
$ 110.00
Received by Date
Recorded by
a
2022
PERMIT VALIDATION
PERMIT NO. 2022
DATE APPROVED 12122/93
EXPIRATION DATE----r--�
DATE ISS ED
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Administrative Authority
TELEPHONE: (619) 564-2246
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SCALE: APPROVED BY: DR fN BY �s
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DATE: /Zq q REVISED
DRAWING NUMBER
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