0011NOTE: ���r
With proper v6iidation
this form constitutes an
encroachmelAt permit
•
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
/ _ I yJ S Subdivision Improvement Permit — Class I I I
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION A J _ 0 4.ti k/4
(Street address or Description of Location) r
PURPOSE OF CONSTRUCTION 11CI:'�. lr�'.�t �J *!u A .JA , Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL �� �- �'v n, �bt ;+
SIZE OF EXCAVATION, IF NEEDED B ' S'.
APPROXIMATE TIME WHEN WORK WILL BEGIN
7 -7 '1 -a 3
APPROXIMATE TIME OF COMPLETION a-2-7-,83
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 c J
i7 (
/c/ f it tom.. ft ` \ ✓ 1' ,L.., .J' ! i " G.
Name of Applicant (please print)
r1 /
Name of Contractor and Job "Foreman
Contractor's License No.
Business Address
Business Address
Telephone No.
Telephone No.
City Business License No.
mppiicanrs Insurance Uompany 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 $ l 4, elia 11
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL
Receipt No
Received by Date
Recorded by
IN q-11
PERMIT VALIDATION
PERMIT NO. f
DATE APPROVED
r
EXPIRATION DATE 7A `� /ry`/-'
DATE ISSUED
By t s,✓ c_..� •,,
Administrative Authority
TELEPHONE: (619) 564-2246
A •V E 5 0
90 ft..approx
BORING FOR A 2"
ELECTRICAL CONDUIT
W A S H I N G T O N
COACHELLA VALLEY WATER DISTRICT
LA QUINTA LIFT -STATION