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2847 (2)• J� •i • ,-------------------------------- —- r--------- —- -- _— _ k , �.� 4' ------------ ; ' " CITY OF LA %U A i NOTE: r A'e ' i t With proper validation - O b .f `� 1t71� +- this form constitutes an encroachment permit',CITY OF LA QUINTA'- ' - APPLICATION FOR PERMIT " PUBLIC wo ^PUBLIC WORKS CONSTRUCTION (ENCROACHMENT) , For the construction of public �or"•private . curbs, driveways, pavements, sidewalks, *park ing lots,, sewers?water 'mains'. and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONSu. - a' • T Subdivision Improvement Permit —,.Class III , DATE: /Dv ' Minor Improvement P rmitClass IV LOCATION OF CONSTRUCTION ! � � ' �r 1 e� < r w . r (Street addressor Description of Location) ( '+ • ti d' PU PQQE..OF CC%NS RUCTION. G�►1 �G1'� ©�G ` Sketch (attach construction plans if appropriate) , CI'�C • � •� � DESCRIPTION OF CONSTRUCTION: VClE. �4i 'D + � � 4� ,, -• DIMENSION OF INSTALLATION OR REMOVAL 1 s•SIZE OF EXCAVATION, IF NEEDED y �.' - - t.' y, • �� APPROXIMATE TIME WHEN WORK WILL BEGIN gV•' ` ~ ' ` ' APPROXIMATE TIME OF COMPLETION ` ? " ESTIMATED CONSTRUCTION COST $ " '' : • (Including removal of all obstruction, materials, and debris; backfilling, com- v _ paction and placing. permanent resurfacing and/or replacing improvements) 4 Y ` In consideration o_f,the granting of this permit, the applicant hereby agrees to: 21 - Indemnify,.defend and save the City, its authorized agents, officers, representatives and employees, harmless from and against any -and all r '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. •" ' ' r _ - +Comply with ell applicable City Ordinences,the terms and conditions of the permit and all applicable rules and regulations of the City of t ' La Quince and to pay for any additional replacement necessary as the result of this work. 1hd�Jt✓� - - ■ C,115LY— k roc9 98� —99. • Signature of Applicant or Agent r L200 E hiRS !i ✓rr o " 39 Name of Applicant (please print) ' Business Address Telep one No. r' SHIP -Ong •CO►1'iyft�VP�Z'7" F *CkC, ?A k F-i` 0� 39 8 .• 105 0 0 . frS n�.t:PooJ .Myc . g — 823 -�" Name of Contractor and Job Foreman _ Business Address + I :, Telephone No. - - .. +t + . + Contractor's License No;, City Business License No. r . L• . c UfvrT D fiOtTo L:A G f 2Z �. Applicant's Insurance Company r Policy Number , FEES: Subdivision Improvement Permit — Class III , y -� Public improvements: 3% of estimated construction costs ' Private improvements: 3%of estimated construction costs, y + Minor Improvement Permit Class IV: See attached schedule 2 7 7 4' ,Inspection Fee ' $' o PERMIT VALIDATION r .� Permit Fee PERMIT N0. C Penalty + Cash Deposit -Surety Bond r -DATE APPROVED 4 if required EXPIRATION. DATE zo 2,0I■ L J TOTAL: $ 60 F ~. i� DATE ISSUED Receipt No... - n Received by Date <<r - Administrative Authority ' Recorded by Telephone: (619) 777 7075 +)i)�kr v) 3 0 i 1r1. •t: l t