2840 (3)'10/26/1998 12:34 7607777155 rCITY':OF'LA QUINTA - PAGE- 01
r
NOTE:
t With prover validation
this fort" constitutes an CITY OF LA QUINTA
encroachment permit
APPLICATION FOR PERMIT
Y. PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
,For the construction of public orprivatecurbs, 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 - Cleas III
DATE ''0r� ~' ,t_ Minerimprovement Pem+itClass lV
qec
LOCATION OF CONSTRUCTION
'"` (BeMt aadtas a Oasaiptlon of 1peoibnlLk
PURPOSE OF'CONSTRUCTIQN Te Sketch (attach construction plans if eppropriatelx`
y SCRIPTIO CONST UCTI N
i
t i xr s
DIMENSION OF. INSTALLXTIi OR REMOVA
It }l r t
!:,=-SIZE•OF EXCAVATIOtd'-lFNEEDED'cem S
APPROXIMATE`TIME WH640RK WILLBEGIN, 112Z
' APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COSrs 1 '
(Including remotral' Of all obstruction, materibls, and ris, bedtfillinp, corn
paotion and placing permanent resurfacing'and/or replacing improvements)
In consideration of the granting of this permit, the applicant hereby agrees to:
= Inpwnmfy'dotend and save the Clty ;its outhotuad agents. officer(, representatives and emptoyaa, hermtea rrem etro agatnat env and etl
denelties, feOUlttei or loss .awlrine:tran'i:leiras or court oemion and arising out of ear accident. ton or darnege to germs of O►OOa%s1' 4
a ,happening or oo "ring p a oro><irhete result of env work undaReKen ynder rho pamtit granted pursuant to thil aatthpnen, .
• Nodfir ale �Admatntr.tive Authority at tam tssentY•bur 1241 hours In dvetwe of the time wgea weft will W awned. .
' COmv$v VA. all epplinble. Vtv Ordinances. the terms and conditions of the permit and act apWteeNs ruts and regulations or tM City or
V Ctrinte end to pay for any additional raplacamam Afro wry as the of this work.
n
'' + • S� i6 G Signature of Applicant r A#nilp 1�,
' Z
Naar of Applicant (please prim) • -Business Address Telephone No.
•��5 .� B2Cb, �'.C,T1��7121 � are BcX 9Q5�Cagchs�lq,
Name of Contractor and Job Foreman Busi en Address Telephorn No.
oob
i Contractor's icvw No. City Business License No.
}, •-71
a1 ur J6I;nQ-�.Go. K— 0=1
' 'A 01 ant's insurures Company ` Policy Number
' FEES: Sobditrlsion Imprarerni;nt Permit — Clete III
Public improvements: 3'A of estimated construction costa
Private improvements: 3% of estimated connflUction costa.
+ Minor Improvement Permit'- Cuss IV: See attached
sche'dule 2774
'Inspection Fee PERMIT VALIDATION
i F i �iPermtee IM
! • `� PERMIT NO.
' Ponalty.
Cook Depeslt•Surety Bend DATE APPROVED
. :. if ro"Ired LSUED
TION DATE
TOTAL: S _
Romig No. -
Received by Da Administrative Authority
R.cord.d br ne: (618) 777-7075