DRVA2017-0012VPcO11-IZ
(gt 4
oI:" DRIVEWAY APPROACH PERMIT APPLICATION
tinance Kevenue Code PD
Applicant Information:
Applicant/Owner (please pjJt name here):
-iL MQS\, (AC,
Applicant Address:
Number Street City State Zip Code
Address or Parcel No. of work location, if different from applicant's address above:
5L-3 J ••Q\ '(j. j\
Number Street City State Zip Code
Date: _I'DJj A3pIicant's Phone No: (Tho ) TiS -
Applicant's Signature:
Approximate Start Date: 5-' i'--ija Approximate Completion Date:
Contractor Information:
Address: '-k'7.() .c. ao\
Number Street City State Zip Code
Phone Number: (1 ). _-• c - 3' Contractors License Number: \ 2 L
City Business License Number:
General Liability Insurance Conipat:
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
Permit Fee $145 = $145 Total Fee
Permit No T)(L/A2Q pirfrtnpn Date P)Qfl 1
Permit Issued by: • Date Issued ZiJ7
Lig—Rrt&-R Aystrotive Authority
Work Inspected by: Permit Completion Date:
Inspector's Signature
Comments:
Note: Driveway approach must be constructed per City of La Quinta Standard #221