0021NOTE:
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
Jwmary 3, 1984 Subdivision Improvement Permit — Class I I I
DATE: Minor Improvement Permit Class IV XX
LOCATION OF CONSTRUCTION Within the Paved and earth sections of various La Quinta roads
within the boundaries of GTE operating area.
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Blanket Permit Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION Maillt"VnUe & Repairs Of This authorization does not include
existing under=md emtmmt & installation. excavations of FAS Roads (Major Roads).
DIMENSION OF INSTALLATION OR REMOVAL Not 1Wre than 80 Permltbe shall notify owrazaty
Lin. Ft. excavated udder blanket permit. Develoftmnt Department a min� of
24 hours prior to start of work.
SIZE OF EXCAVATION, IF NEEDED 3' x 4' Bell holes and
installation of new services
APPROXIMATE TIME WHEN WORK WILL BEGIN Notify City
24 hours in advance of any wozk.
APPROXIMATE TIME OF COMPLETION Pemit expires 1-3-85
ESTIMATED CONSTRUCTION COST $ N/A
(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:
Separate; permits are ro ruizzy2 for F;Z
Roads.
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
3`17 — S 7 7 5�
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 $ N/A
Permit Fee $ 150.00
Penalty N/A
Cash Deposit -Surety Bond
if required _
TOTAL: $
Receipt No. _
Received by
Recorded by
N/A
150.00
Date
PERMIT VALIDATION
PERMIT NO. 021
DATE APPROVED 1-3-34
EXPIRATION DATE 1-3-85
DATE ISSUED 1-3-85
By
Administrative Authority
TELEPHONE: (619) 564-2246