3690NOTE:
With proper validation
this form constitutes an
encroachment permit
CITY OF .LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
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 .
i�P�. 2002.
� Subdivision Improvement Permit — Class I II
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION Corner of LOU Ls- Q"nta Drive a0d Galen BAY
sap 2001-'712,o Ondr 11mi;. Restaurmt
(Street address or Description of Location)
PURPOSE OF.CONSTRUCTION Pree"'a Grad'28 a> Pig Sketch (attach construction plans if appropriate)
DESCRIPTION OF -CONSTRUCTION see Attached Ce"Itiions
Pimc.Ue Gradb* and Paving
DIMENSION OF INSTALLATION OR REMOVAL Sae P1 8
200 % 150
SIZE OF EXCAVATION, IF NEEDED See Places
APPROXIMATE TIME WHEN WORK WILL BEGIN 06/03/02
APPROXIMATE TIME OF COMPLETION ASl31�A�
ESTIMATED CONSTRUCTION COST $ 1��s
(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 a 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/
Signature offApplicant or Agent
Ste. J. Rau PQer office Box 626 1000 P&IM, (760) 343--3461
Name of Applicant (please print) Business Address Telephone No.
B.J.S. Canatruction >Poat ,Office Boas 626 1000 P&Uw (760) 343-3461
Name of Contractor and.Job Foreman Business Address Telephone No.
B 651557
Contractor's License No. City Business' icense No.
State Nkmd1634612-01
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:
Inspection Fee $ 3'60`00
Permit Fee 100.00
See attached schedule
Penalty
Cash Deposit -Surety Bond
if required Pin Check Credit . 0730)
TOTAL:,
Receipt No.
Received by Date
Jul JUN 102002
�m : 8ftRY0FL*AQUIffA
PERMIT VALI
PERMIT NO. 3676
DATE APPROVED May 31* 2002
EXPIRATION DATE Kay, 31, 2003
-�✓i�% ,.
DATE ISSUED
By
ministrati
Recorded by Telephone: (760) 777-