DRVA2017-0006GDcX
DRIVEWAY APPROACH PERMIT APPLICATION
Applicant Information:
Applicant/Owner (p/ease pjjpj name here):':
Applicant Address:
Number treet
- I • WI IhiC ,euhio r I.,
State Zip Code
Address or Parcel No. of work location, if different from applicant's address above:
Number Street - - ' City -
Date: /22/J. App iças PrNo: -CO')
Applicant's Signature:
Approximate Start Date: .i\ijj Approximate Completion Date:
State Zip Code
'Contractor Information:
Addrèss q20 &1 L. vw4.
Nuni.bei Street I City State Zip Code
Phone Number: 'O ,cSContractors License Number:.______kSq _____________
City Business License Number: &
General Liability Insurance 4tf?i. Policy. No. b19
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
. 4r2_
Permit Fee.- $TotaI Fee
Permit Nöi21)i_2011t.iExpj'ratipn,
'Permit Issued by: Date Issued iifl.
Si of A " trative uthority
Work Inspected by:'_________________ Permit Completion Date: ._•J_l_
Inspector's Signature
Comments:
Note: Driveway, approach must be constructed per City of La Quinta Standard #221
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