2110;,jNOT.Fi:
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
DATE
3/24/94
LOCATION OF CONSTRUCTION
Subdivision Improvement Permit — Class I I I
Minor Improvement Permit Class IV
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION MOVe Equipment Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION CAT 623 Scraper Haul Route: Jefferson St south to
48th Ave.
DIMENSION OF INSTALLATION OR REMOVAL 14'6"H,12'W
_65'L. 60,000 lbs Haul Date: 3/24/94
Pilot Car Required
SIZE OF EXCAVATION, IF NEEDED a —
APPROXIMATE TIME WHEN WORK WILL BEGIN
D
APPROXIMATE TIME OF COMPLETION
MAR 2 4 1994
ESTIMATED CONSTRUCTION COST $ B
(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:
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.)
Signatur, of Applicant or Agent
Forstan Co,Inc P.O.Box 625 Colton CA 92324 (909) 877-2126
Name of Applicant (please print) Business Address Telephone No.
Allen Wood Equipment Retal
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 $ 10.00
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $ 10.00
Receipt No.
Received by Date
Recorded by
2110
PERMIT VALIDATION
PERMIT NO. 2110
DATE APPROVED 3/23/94
EXPIRATION DATE .21 n(M 1 —''1 ``1
DATE ISSUED 31
A ministrative Authority
TELEPHONE: (619) 564-2246
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