DRVA2017-00194/1'fl
&
OF DRIVEWAY APPROACH PERMIT APPLICATION
Applicant Information:
Applicant/Owner (please Drint name here): c Locs\ E)
Applicant Address:
k1 Lc
Number
Address or Parcel No. of
S O(Q\c,u,
Number Street
Street City State Zip Code
work 1pcation, if different from applicant's address above:
City State Zip Code
Date: _/j/ V Applicant's Phone Nc . .( 7 6 0 ) -7 -7 5. vj.9 L 3'
Applicant's Signature:
Approximate Start pate: ° / \ I \1 Approximate Completion Date: \, \5 ,
Contractor Information: S
Address:
Number Street City ( '32Z Code
Phone Number: (7(0 ) 77S- Y)3 r •Contractors License Number: ______ 7 21
City Business License Number: S
General Liability Insurance Company: Policy No. £\ 5 I o- 33oS
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. The Hub Counter (760) 7777125.
Please Note: Inspections are normally performed Monday through Friday. between 8am and 4pm
Permit Fee $152 + $5 Technology Enhancement Fee = $157 Total Fee
Permit 01 Expiration Date
Permit Issued by: Date Issued 9 / 1?/ '7
Work Inspected by: Permit Completion Date: I /
Inspector's Signature
Comments:
Note: Driveway approach must be constructed per City of La Quinta Standard #221