DRVA2016-0016-Pr UYA O QDtLL,
S .
or DRIVEWAY APPROACH PERMIT APPLICATION
Finance Revenue Code PD
Applicant Information: .
Applicant/Owner (please p_th'Lt name here):
Applicant Address: 77, '4' L->' X <'4 0 (29 (3
Number Street . . City State Zip Code
Address or Parcel No. of work location, if different from applicant's address áboye:
<''9cic2 f
Number. Street City
Date: IIA pplic an
S
hone No: (7C a •P
Applicant's Signature:
Approximate Start Date:'///t( Approximate Completion Date:"? /3a//(
State Zip Code
Contractor Information:
Address:
Number Street City State Zip Code
Phone Number: Contractors License Number: "G 2 5 7ç
City Business License Number: 0/' t' C) /
General Liability Insurance Company: J)O22 ,44' '7 Policy No.
Request for Inspection - Please call (760) 777-7097 before 1:30pm to request an inspect/oh at least 24
hours prior to your requested inspection date. Public Works Counter (760) 777-7075.
P/ease Note: Inspections are normally performed Monday through Friday between 8am and 4pm
Permit Fee $4-4.5_= $145 TOtal Fee
Permit No. -Expiration Date ji7lij7 .
Permit Issued by: Date Issued 1`2,11111(o
Signature f Ad inistra ive thority
Work Inspected by: Permit Completion Date:.-/-/,
Inspector's Signature .
Comments:
Note: Driveway approach must be constructed per City of La Quinta Standard #221