2171NOTE:
With proper validation
this form constitutes an CITY OF LA QUINTA
encroachment permit
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
dA)t; l"Rlp ONF_Q:sf ZE LOAD F -,
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
DATE: 5"13-94 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION Haul Permit
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION
Section of Mobile Home
DESCRIPTION OF CONSTRUCTION
DIMENSION -OF INSTALLATION OR REMOVAL 1 w
85'1 40,0001bs.
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
Sketch (attach construction plans if appropriate)
Haul Route: Jefferson at City limits
s/b to Ave. 52 w/b to Bermudas South
to Colima. 1.
I r,
Haul nate:" ji MAY R 1994
pilot car
APPROXIMATE TIME OF COMPLETION ,
ESTIMATED CONSTRUCTION COST $ Fsraittesis responsible Or verifying
(Including removal of all obstruction, materials, and debris, backfilling, com- the clearance ov rhead of signs
paction and placing permanent resurfacing and/or replacing improvements) utility lines etc.
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.
0i nature of Applicant br Age`�t -
TRUCKING P.O. BOX 9877 AN BERNARDINO (90 9) 883-6867
Name of Applicant (please print)
Business Address
Name of Contractor and Job Foreman Business Address
Contractor's License No.
on file
Telephone No.
Telephone 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
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No
10.
$ 10.
Received by Date
PERMIT VALIDATION
PERMIT NO. 2171
DATE APPROVED 5-13-94
EXPIRATION DATE 5'2-0-944
DATE ISS1JED..
By WtA
Administrative Authority
Recorded by II TELEPHONE: (619) 564-2246
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REQUEST FOR INSPECTION
24 HOUR ADVANCE NOTICE
DATE
PROJECT LOCATION PERMIT NUMBER
/—T CoD�L�ts c a. -z/7 �.
CONTRACTORS NAME
PHONE NUMBER
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COMPACTION TEST
COMPACTION TEST
Subgade.................. ❑
Base ........................
❑ Grading ....................
❑
Curb & Gutter .......... ❑
Drainage ..................
❑ Formwork..................
❑
Trenches ................ ❑
Striping ....................
❑ Structural Steel ........
❑
Paving (Asphalt) ...... ❑
Signing ............. :......
❑ Backfill ......................
❑
Paving (Concrete) .. ❑
Landscaping ............
❑ Excavation ................
❑
Driveway Approach
M�Y-> TUESDAY WEDNESDAY THURSDAY FRIDAY
78-105 CALLE ESTADO • LA OUINTA, CALIFORNIA 92253 9 (619) 564-2246