2982NOTE:
With proper validation
this form constitutes an CITY OF LA QUINTA
encroachment permit
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
0F Ti18�
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
"?371-CPI
(Street address or Description of Location)
PURR�P`OS—E QF CONSTRUCTION -511e667 yE
ESC IPT ON OF CON RU T O
DI I 5HTI0 �OV9�
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
Subdivision Improvement Permit — Class I I I
Sketch (attach construction plans if appropriate)
/ G
APPROXIMATE TIME OF COMPLETION . 66 01-009 f .
ESTIMATED CONSTRUCTION COST $
(Including removal of all obstruction, materials, and debris, backfihing, com- �%.. r
paction and placing permanent resurfacing and/or replacing improvements) �(/�1,L1 i(�jt.y v r J
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 t of t s
Signature of Appl' t or Agent
Name of Applicant (please print) /p{ 6s L Business Address ?i�G/—/i�.e� Telephone No. �p
Name of Contractor and Job Foreman Business Address3i� y �3Telephone No. -70 —
-7 7 s =-7SDP
Contractor's License No. City Business License No.
1A S, 60 - c,? *%-Oso26
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 2774
Inspection Fee
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by
$
$_ . aIV, a
Date
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
Recorded by 111 Telephone: (619) 777-7075
:k.
TRANSMITTAL
l '
DATE: , '1999
TO: Mike�A00(o g I�lpbL�
FIRM: TAGE
FROM: Carol
DIRECT #: 619-794-6172
FAX #: 619-793-2395'
0
SUB BRAE BURN — PERMIT FOR STREET & ST DRAIN
A
IMPROVEMENTS .
TRANSMITTING VIA CALIFORNIA OVERNIGHT:
.1 check in the amount of $216.24 for renewal of existing permit
1 completed permit application i
COMMENTS: