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CITY OF LAQUINTA
4C 11 D PERMIT APPLICATION
Finance Revenue Code PD
Applicant Information:
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Applicant/Owner (please gdnt name here): r7i'ii fT5/-epn e S/i a e. 1
Applicant Address:
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Number
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Street
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City
1CM 11 91.29s"3
State Zip Code
Address or Parcel No. of work location, if different from applicant's
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Number Street City - -
State Zip Code
Date: 11511/I['1 s I Applicant's Phone No:
Applicant's Signature: ,fciu A Pr S1i.i
Approximate Start Date: I ?1/5/T.'1Approximate Completion Date: I J1 t 1
Contractor Information: .j— / j.. Cs.s/-c'r 0I1C1& - JCCK
Address: ______
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Number Street City State Zip Code
Phone Number: L'1Db ) F OO O?.S 'Contractors License Numbed rSO.3
City Business License Number:
General Liability Insurance
No.1 /3lw 1
Request for Inspection - Please call (760) 777-7097 before 1:30pm to request an in
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hours prior to your requested inspection date. Public Wo
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Please Note: Inspections are normally performed Monda
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Inspection Fee $20 + Permit Fee $10 = $30 Total Fcc- / '-j5 -
Permit No. xpirat on Datel
Permit lssuédby-
Date Issued ri,r1vci
—I,ature of Administ Authority
Work Inspected by:
Permit Completion Date: F7/77 /6'
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Inspector's Signature
Comments:
Note: Driveway approach must be constructed pe
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City of La Quinta Standard #221
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CeQLL 1vt / c2
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