3693NOTE:
With proper validation
this form constitutes an
encroachment permit
CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
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
DATE: A7/11 /09
LOCATION OF CONSTRUCTION 78-655 SAGUARO ROAD
Subdivision Improvement Permit — Class III
Minor Improvement Permit Class IV
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION REPLACE A BURIED NON ENT Sketch (attach construction plans if appropriate)
TERM WITH A 25 SPLICE PIT REQUIRED
DESCRIPTION OF CONSTRUCTION SEE ATTACHED SPECIAL. CONDITIONS AND
DRAWING NUMBER ONE
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED 4' x 6' SPT TCX PZT
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $ 7MAY)
(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 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 of Applicant or Agent
VPRT70N (`0A41 t9TP,A"TTQX1,R 74r% N 91WRTAIR WAY PATM gPQTNorR rA 099f%9 760 RO;A 171r%
Name of Applicant (please print) Business Address Telephone No.
RCT a G:01nM'';a1TrA,*r*TQV9 11901 HARRRI, STRAP. MT'RA l.tkl+!'A i'A 70;n 1Aq 111411.
Name of Contractor and Job Foreman Business Address Telephone No.
37ASR7
Contractor's License No.
All 1Al2
City Business LicensezNo.
Applicant's Insurance Company I Policy Number ifnl /A\ f I
FE1ES: 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 $ 21.00
Permit Fee 100.00
Penalty .
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
$ 121.00
L
Received by Date
JUL I o Y002
CITY OF LAQUINTA
FINANCE DEPT
PERMIT VALIDATION
3693 =
PERMIT NO.
DATE APPROVED
7/11/02
EXPIRATION DATE ni.m /Qi
DATE IS_S)U_E,D,,.c
By
dminlistrative Authority
Recorded by 11 Telephone: (760) 777-7075