DRVA2017-001892
lID? A L IIrr S
j SEP O 8 2017
I CITY OF LOUJ
Y DRIVEWAY APPROACH PERMIT APPLICATIOF UNIRTNYD EWPDN
Applicant Information:
Applicant/Owner (please pijol name here): ---
Applicant Address:
Number Street S City State Zip Code
Address or I No. of work different from applicant's address above:
Number Street City State Zip Code
Date: Th Applicant's Phone No: (_7CC) 77 S. \'
Applicant's Signature:
Approximate Start Date: / ' / \ 1 Approximate Completion Date: / & /
Contractor Information:
Address:
CA.
Number Street. City State Zip Code
Phone Number: (7L 0) 7 7 S - I i '.i Contractors License Number: 1 G 1
City Business License Number:
General Liability Insurance 'cS Policy No. 1c \O) '33O-S
Request for Inspection - Please call (760) 777-709.7 before 130pm to request an inspection at least 24
hours prior to your requested inspection date. The Hub Counter (760) 777-7125.
Please Note: Inspections are normally performed Monday through Friday between 8am and 4pm
Permit No. Deli/4rn7—p's ExPiron Date i i r /
Permit Issued . Date Issued i / 1 7
't-ignatur& of Admfntrative Authority
Work Inspected by: S Permit Completion Date: / /
Inspector's Signature
Comments:
Note: Driveway approach must be constructed per City of La Quinta Standard #221