DRVA2016-0015If .
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OF • DRIVEWAY APPROACH PERMIT APPLICATION
Finance Revenue Code PD
Applicant Information:
Applicant/Owner (please gEj 2t name here):
Applicant Address: Z, '4' /'/ J" 'f X <' 0 ciV 7? 2'( 3
Number Street City • State Zip Code
Ad_Øress or Parcel No. of work location, if different from applicant's address above:
) .2 U,'0 -')i, (/2 ( •P.22-' ''
Number. Street City State Zip Code
Date: _I_/_ AppIica\ Phone No: (7C 6) .37P-
Applicant's Signature:
Approximate Start Date:' /.c /( Approximate Completion Date:'/3G//
Contractor Information:
Address:
Number Street City State Zip Code
Phone Number: Contractors License Number: 0 7ç-
City Business License Number: 0/ (if C) C) /
General Liability Insurance Company: )Xc92 '7 Policy No.
Request for Inspection - Please call (760) 777-7097 before 1:30pm to request an inspection at/east 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 $445_= $145 Total Fee
Permit No. Expiration Date j/V1/J7
Permit Issued by: Date Issued
nustr ive A
Work Inspected by: Permit Completion Date:
Inspectors Signature
Comments:
Note: Driveway approach must be constructed per City of La Quinta Standard #221