4445 (2)ffr
NOTE;__--
With.proper validation
this form constitutes an >i
encroachment permit CITY OF L'A•QUINTA
APPLICATION FOR PERMIT
PUBLIC .WORKS CONSTRUCTION (ENCROA
For the construction of public or private curbs, driveways, pavements, sidewa
and other like public works improvements in connection with MINOR IMPROVEMI
3ULY 14, Subdivision I 2005 DATE: Minc
LOCATION OF CONSTRUCTION 54-060 RIVIERA WAY PM 33015 PGA W.
(Street address or Description of. Location)
RAPETSE OF CONSTRUCTION OFF SITE WATER AND ON SITE Sketch I
DESCRIPTION OF CONSTRUCTION ' FS NO_ 05076
DIMENSION OF INSTALLATION OR REMOVAL -SF.R PS NO, - 05076
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SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME.WHEN WORK WILL BEGIN TBD VLA
APPROXIMATE TIME OF COMPLETION TED ESTIMATED CONSTRUCTION COST$ 17A014 +-5, IRf1 IRI-934 (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, . Mend, 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.
g Applicant or Agent
DENNIS SCM-L: FIRST PACIFICA DEV. 300 N. STATE.ST. REMANDS, CA (909) 841-1381
Name of Applicant (please print) Business Address Telephone No.
SELF
Name of Contractor and Job Foreman Business Address Telephone No.
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Contractor's License No. City Business License No. ,
SAT-0 INSURANCE SERVICES O4GLP1007475
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
Inspection Fee $ 5460.00
Permit Fee 100.00
Penalty'
Cash Dep1sit-Surety Bond
if required
TOTAL:
Receipt No.
(1,000.00)
$ 6560.00
Received by Date
Recorded by
4445
PERMIT VALIDATION
PERMIT NO. 4445 '
-7 - I ?,--•? .
DATE APPROVED
EXPIRATION DATE -7" �b
DATI I<S,SU D -
By -
Administrative Authority
Telephone: (760) 777-7075
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