0267C
NOTE:— '
With proper validation
this form constitutes an. CITY OF LA:, QUINTA
encroachment permit'
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
For the construction' of public 'or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains .
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS .
DATE: July 2, 1987 .. •
Subdivision Improvement Permit — Class I I I RX
Minor Improvement Permit Class IV
LOCATION OF,CONSTRUCTION Tract 22432=1
(Street addressor. Description of Location)
PURPOSE OF CONSTRUCTION S --h4-+ 1.4' 49 A Sketch (attach construction plans if appropriate)
DESCRIPTION,OF CONSTRUCTION
:DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN.
See approved plans.
USA Inquiry No.
APPROXIMATE TIME OF COMPLETION' `
ESTIMATED CONSTRUCTION COST $ Date Issued
(Including removal of all obstruction, materials -and debris, backfilling, com-
paction and placing permanent resurfacing and/or replacing improvements)
In consideration•of'the granting of this permit, the applicant hereby agrees to -
Indemnify, -defend
o-Indemnify,-defend and save the City, its authorized agents, officers, representatives and employees, harmless from and against any and all
penalties, liabilities or loss resulting from claims or court action and arising out of .any accident-, loss or damage to persons or property
happening or occurring as a proximate result of any work undertaken under the permit granted pursuant to, this application.
Notify the Administrative Authority at least twenty-four (24) hours in advance of the time when work will be started.
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules and regulations of the City of
La Quinta and to pay for any additional replacement necessary as the result of this work.
Signature of Applicant or Agent
National Mortgage and Land 75-005 Country Club Drive, Palm Desert .5682828
Name of Applicant (please print) Business Address `. Telephone No.
Name of Contractor and Job Foreman Business Address *. Telephone No. ,
Contractor's License No. City Business License No.
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Class I I I
Public improvements: 3% of estimated construction costs,
Private improvements: 3% of estimated construction costs
Minor Improvement Permit - Class IV: See attached schedule
Inspection Fee $ 1,331.32'
Permit Fee' 10.00
Penalty
Cash Deposit -Surety Bond
if required (On File)
TOTAL:$_1,341.32.
Receipt No.
Received by Date
Recorded by
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED 7 4 /i',7
EXPIRATION DATE h/
DATE ISSU'ED�
,B Y
V Administrative Authority
TELEPHONE: (619) 564-2246