0003'a
`NOTE:
With proper validation
this form"tonstitutes an
encroachment permit
• . 0
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
Subdivision Improvement Permit — Class I I I
DATE: 21, 19$3 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 46-405 Washington Street, La Quints, CA
IAT: 2 Tract: 2043
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Imtall and Maintain a Sketch (attach construction plans if appropriate)
one -inch dcmestic water service
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
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
Coachella Valley Plater .District P. O. Box 1058, Coachella, CA 92236 (61.9) 398-2651
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 III
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $ f- 0 in
Permit Fee Al
Penalty
Cash Deposit -Surety Bond f
if required 1114
r
TOTAL: $
Receipt No.
Received by
Date
NT c,, If
PERMIT VALIDATION
PERMIT NO. 7 /
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
Recorded by 11 TELEPHONE: (619) 564-2246
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NOTE:
With proper validation
this form constitutes an
encroachment permit
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
Subdivision Improvement Permit — Class III
DATE: MARCH 21, 1983 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 46-405 WASHINGTON STREET' LA QUINTA" CA.
LOT• 2 TRACT• 2041
(Street address or Description of Location)
PURPOSE OF'CONSTRUCTION INSTALL AND MAIM'AIN A Sketch (attach construction plans if appropriate)
ONE INCH DOMESTIC WATER
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
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 res is work.
ignature of Applic t or Agent
COACHELLA VALLEY WATER DISTRICT P: O. BOX 1058 M- A(TF'r',T,A., CA_ 922-16 (til q) -IqR-2Is, ,1
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 III
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs --'
Minor Improvement Permit — Class IV: See attached schedule •
Bea
Inspection Fee $
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by
Recorded by
Date
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED _
EXPIRATION DATE
DATE ISSUED
By
TELEPHONE: (619) 564-2246
Administrative Authority