2107�..,.N0-tE:
With proper validation
this 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
DATE: 3/23/94
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Move Equipment
DESCRIPTION OF CONSTRUCTION CAT D8H DOZER w/Slope
Board Detached & Reloaded
DIMENSION OF INSTALLATION OR REMOVAL 14'6tt fl; 13"8"W
85* L , 75.000 lbs
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $
Subdivision Improvement Permit— Class III
Minor Improvement Permit Class IV
Sketch (attach construction plans if appropriate)
Haul Route: Jefferson St.
South to 48th Ave.
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Haul Date : 35E23M
(Including removal of all obstruction, materials, and debris, backfilling, com- pilot Car Required
paction and placing permanent resurfacing and/or replacing improvements)
In consideration of the granting of this permit, the applicant hereby agrees to:
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 wort; 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
Forstan Co. Ins Y.O.Box 625 Colton, CA 92324 (909) 877-2126
Name of Applicant (please print) Business Address Telephone No.,
Allen Wood Eglipment Rental
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No.
City Business License No.
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 $
Permit Fee 10.00
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $ 10.00
Receipt No.
Received by Date
Recorded by
PERMIT NO
21.07
PERMIT VALIDATION
2107
o;
DATE APPROVED 3/23/94
EXPIRATION DATE 31 a y 15 y
DATE ISSUED
By
dministrative Authority
TELEPHONE: (619) 564-2246
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