2150NOTE:,;
W
ItFi 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: 4---25-94
LOCATION OF CONSTRUCTION 54-385 Carran.za
Subdivision Improvement Permit — Class I I I
Minor Improvement Permit Class IV
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Driveway Approilch Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN 4-25-94
Per Riverside Co. Std. No. 207
(attached)
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $ t
(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.
t
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 f applicable rules and regulations of the City of
La Quints and to pay for any additional replacement necessary as the result of this work. n
P.O.Box
ignature of AVji licant or Agent
La Quinta . CA 92253 564-2783
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
652815 2845
Contractor's License No. City Business License No.
on file
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Class I I I Q
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construct'4n c
Minor Improvement Permit — Class IV: See attached schedule 9
Inspection Fee $ 20 By
Permit Fee 10
PERMIT NO. 2150
2150
PERMIT VALIDATION
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by
Recorded by
$ 30
Date
DATE APPROVED 4-25-94
EXPIRATION DATE 5-7-94 11
DATE ISS(IED. 44-25-94
By
Administrative Authority oo-'
TELEPHONE: (619) 564-2246
NOTE:
With proper validation
this form constitutes an
encroachment permit CITY OF LA. _QUINTA---
APPLICATION FOR PERMIT
-PUBLIC WORKS CONSTRUCTION ANCROACHMENT)
nor the construction of public or private curbs, driveways, paventerm, sidewalks, parking lou, sewers, water nujrp
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
DATE: �J
LOCATION OF CONSTRUCTION
(Street address or Description of
PURPOSE OF CONSTRUCTION
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SI2E OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
1 M -
Subdivision Improvement permit — pass III
Minor Improvement Permit Class IV
Sketch (attach construction plans if appropriate)
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST S
(Including removal of all obstruction, materials, and debris, backfilling, tom.
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 ssthe City. �authorized
Pertelttes.ag"' - officers, repnmmstives and employees. harmless from and agawat ad all
l w liabilities W Ion refultinItsny an
froom Claims orCourt action and arising out of any accident. foes or
frappe^'^g or occurring es • ororeiertete result of any work unken under the permit granted pursuant to �eooliotion. to person$ « � y
Notify the Administrative Authority at least twenty-four 1241 hours in advance of the time when work w+ll be started.
ComWv wia all spay foe City Ordinances, the awns and Conditions f the permrt and ell amikaple rules and reguletiona of the city of
V Dyeing and to pay for any additional replacement necessary as th It of this
I
V&W
(_Cr� —tun'of ppliant or Agent
Jct A (Please
�L 61 (9 Applicant (Please print)n Business Address
,1 1 A /% �, 11) I d ,, n Telephone Na
ryanu of Cffractor and Job Foreman
1�75a /s
Contractor's License No.
Business Address Telephone Na
a
,n City Business License No.
` v (—/A C,
Applicant's Insurance Company
Policy Number
FEES: $ubalvlslon Improvement Permit — Class 111
Public improvements: 396 of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee
3ermit Fee
3enalty
:ash Deposit -Surety Bond
f required
TOTA L.
leceipt No.
S
'lecelved by Data
3ecorded by
PERIyIiT VALIDATION
PERMIT NO.
DATE APP
EXPIRA ON DATE
.i
DATE UED
By
TELEPHONE: (619) 564-2246
/ �..............
Administrative Authority
TI