DRVA2016-0012OF DRIVEWAY APPROACH PERMIT APPLICATION . S
Finance Revenue Code PD
Applicant Information:
Applicant/Owner (please jt name here):.
67 QV VILLJ4 c?22 . Applicant Address:
Number Street City State Zip Code
Address or Parcel No. ofwork location, if different from applicant's address above:
Number Street . . City State Zip Code
Date: Applicant 's h e No: 7i'0) it)
Applicant's Signature: _______________________
_&J~Approximate Completion Date: Approximate Start Dates
Contractor Information:
Address: .
Number Street• City State Zip Code
Phone Number: Contractors License Number:
City Business License Number:
-
General Liability Insurance Co Policy No.
Request for Inspection - Please call (760) 777-7097 before 1:30pm to request an inspection at least 24
hours prior to your requested inspection date. Public Works Counter (760) 777-7075.
Please Note: Inspections are normally performed Monday through Friday between 8am and 4pm
Permit Fee $145 = $145 Total Fee
Permit No. ,. Expiration Date 1/
Permit Issued by:
-
Date Issued I /
Signature of Administrative Authority
Work Inspected by: Permit Completion Date: II
Inspector's Signature
Comments:
Note: Driveway approach must be constructed per City of La Quinta Standard #221