2169V7
NOTE:
With proper validation
this form constitutes -an -
encroachment permit
CITY OF
APPLICATION
LA QUINTA
FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
OMEE -TiZ►P 4)41Y,1�S ► ZLI`z. LOAD Pe2-wl il-
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 I I
DATE: 5-13-94 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location) '
PURPOSE OF CONSTRUCTION
Haul Permit
DESCRIPTION OF CONSTRUCTION Section of Hobile Home
DIMENSION OF INSTALLATION OR REMOVALI615h 141`t
85'1 40,0001bs
SIZE OF EXCAVATION, IF NEEDED
Sketch (attach construction plans if appropriate)
Haul Route: Jefferson at City limits
s/b to Ave 5 --tu-Bgrmudas south
to Colima D A 0
Haul Date:
MAY 13 X994
Pilot Car '
APPROXIMATE TIME WHEN WORK WILL BEGIN
Peraitteeis respons or verifying
APPROXIMATE TIME OF COMPLETION the clearance mre of all signs
ESTIMATED CONSTRUCTION COST $ - - utility linea etc.
(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 T
La Quinta and to pay for any additional replacement necessary as the result of this wo.k.. '
f,
=ring
ure of Applicani-6r Agent D
Triple R Trucking 1243' North Placentia (714) 996-6129
Name of Applicant (please print) ► Business Address • Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No
on file
City Business License No.
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.
10
$ 10
Received by Date
2169
PERMIT VALIDATION
PERMIT NO. 2169
DATE APPROVED
5-13-94
EXPIRATION DATE "g. -m-0
DATE ISSUED S — 1 3 t
By ::994 dles"6�
Administrative Authority
Recorded by 11 TELEPHONE: (619) 564-2246
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