DRVA2017-0005UA V/'1 271 atJ5
FEB 10 20117
DRIVEWAY APPROACH PERMIT APPLICATION
Finance Revenue Code PD
Applicant Information:
Applicant/Owner (please pjjtt name here): 17.\/o'e
Applicant Address: L(DS 4c'Uavü 7o)w Lnc c.. c2.s3
Number Street City State Zip Code
Address or Parcel No. of work location, if different from applicant's address above:
Number Street City State Zip Code
Date: Applicant's Phone No: -itio )
Applicant's Signature:
Approximate Start Date: -/t3/r7 Approximate Completion Date: -if_i.jj
Contractor Information:
Address: ( ( or 1(M)
Number Street City State Zip Code
Phone Number: () Contractors License Number:
City Business License Number:
General Liability Insurance Company: 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
'%$2I O
Permit Fee $f45 = $145 Total Fee
Permit No.P,V/O/?0!Expiration Date -i'frj7
Permit Issued by: Date Issued
Si na UFe -oQ inisthhive Authority
Work Inspected by: Permit Completion Date: _/_I
Inspector's Signature
Comments:
Note: Driveway approach must be constructed per City of La Quinta Standard #221