DRVA2017-0007V(lU1oti- oco7
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DRIVEWAY APPROACH PERMIT APPLICATION
Nnance Kevenue Code PD
Applicant Information:
Applicant/Owner (please pjjt name here)
Applicant Address:
Number Street - City Stäte Zip Code
Address or Parcel No. of work location, if different from applicant's address above:
Number Street City State Zip Code
Date 2_/jIJ Applicant's Ph .io (1t2.)) 15) cas
Applicant's Signature
Approximate Start Date: Approximate Completion Date:
Contractor Information: ~ I
f , ~-) Address
Number - Street City State Zip Code
Phone Number: Contractors License Number:
City Business License Number:
I General Liability Insurance 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 I
Permit Fee 1Z5-= *wq.iotal Fee
Permit No.t2* ori-1- Expiration Date jiiS , S
Permit Issued by:1 . Date Issued
Sidn ãf'4rnjistra ye Authority
Work Inspected by:: Permit Completion Date:
Inspector's Signature
Comments: . --
Note: Driveway approach must be constructed per City of La Quinta Standard#221