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NOTE:
With proper validation
.this°form constitutes an CITY OF LA QUINTA
ericroachment permit
APPLICATION FOR PERMIT
{ PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
543-71299-I
IN
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
May 21 '1990 Subdivision Improvement Permit —Class III
DATE: -Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION Ave. 54 NIS 800; W/O Madison & Madison E/S 150' SIO
Airport Blvd and Madison Street at Ave. 48
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Sketch (attach construction plansrif appropriate)
DESCRIPTION OF CONSTRUCTION Reference: Permit 22X 513
all conditions of permit 513
DIMENSION OF INSTALLATION OR.REMOVAL sham apply to this permit
4 traffic control revision is as
SIZE OF EXCAVATION, IF'NEEDED approved 5/18/90
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $
(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: I Y
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, a
y
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 anyeadditional replacement necessary as the result of this work. ,
Signatur
e
of Applicant or Agent
GTE California e3 17x.3 o
-Name of Applicant (please print) Business-Kddress Telephone No.
r. .
Name of Contract6r'and Job Foreman Business Address ,Telephone No.
Contractor's License No. City Business License No.
Applicant's Insurance Company Policy Number
3
FEES: Subdivision Improvement Permit — Class l II
-,Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs ,
o Q C
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee
Permit Fee,,
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
$ -0-
$ -0-
Receipt No:
Received by Date
PERMIT VALIDATION
PERMIT NO. 0655
DATE APPROVED 5/21/90
EXPIRATION DATE 12/31/90
DATE ISSUED $''/21/90'a'i
Administrative Authority
Recorded by 11 TELEPHONE: (619) 564-2246
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NOTE: ,
With proper validation
this'form constitutes an
encroachment permit
0
4
X543 -71299-I
CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains
and- other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
May 21, 1990 Subdivision Improvement Permit — Class II I
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION Ave. 54 NIS 200; W/O Madison & Madison E/S 150' SIO
Airport Blvd and Madison Street at Ave. 48
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Sketch .(attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION Reference: Permit # :R$X 513
all.conditions of permit 513
` DIMENSION OF INSTALLATION OR REMOVAL shall apply to this permit
traffic control revision is as
SIZE OF EXCAVATION, IF NEEDED approved 5/18/90
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF_ COMPLETION
ESTIMATED. CONSTRUCTION COST $
(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 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
GTE California e3'J�_3
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
.F
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 $, 0—
Permit
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $ —0—
Receipt N �.
Received by _
Date
a 0655
PERMIT VALIDATION
PERMIT NO. 0655
DATE APPROVED 5/21/90
EXPIRATION DATE 12/31/90
r DATE ISSUED 5./21/90
By
Administrative Authority
Recorded by 11 TELEPHONE: (619) 564-2246
I