0022T
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NOTE:'
With proper validation
this fe4-m constitutes an
encroAchment permit
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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 II
' DATE: �/� /7r i7 ) / / �. �Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 1,4OV4 '�,/0,,1 5 i9 f71_*0/;/>.�'1?../J /`///!?
(Street address or Description of Location)
PURPOSE QF CONSTRUCTION
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED „,_'Z1 w;*- --?'�
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $ 4-,41" -^_n
l
(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:
Sketch (attach construction plans if appropriate)
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.
ame of Applicant (please pri
Name of Contractor and Job Foreman
Contractor's License No.
re of,Applicant or Agent
Business Address Telephone No.
Business Address Telephone 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 $ ,K�
Permit Fee
r
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $
Receipt No.fl
Received by ( �'t�"��- Date
`x.22
PERMIT VALIDATION
PERMIT NO. �1) 'ate_
DATE APPROVED
EXPIRATION DATE 144 _ 1-0"
DATE ISSUED Z-/0-9,
By
Administrative Authority
Recorded by 11 TELEPHONE: (619) 564-2246
r' z7i,
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
��� I Subdivision Improvement Permit —:Class III
DATE: Minor Improvement Permit Class rV
LOCATION OF CONSTRUCTION. W NNA IM TOL) SNKTU EEM AVEUUE Sit, Aj Q
AVENWE
(Street address or Description of Location)
PURPOSE OF CON
DESCRIPTION OF CONSTRUCTION
DIMENSIO^::;F !^!•Si:',L!_ATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED X khQQ
-- DIEPTH
Sketch (attach construction plans if appropriate)
APPROXIMATE TIME OF COMPLETION W&e—A . 10 //iq 6�—
ESTIMATED CONSTRUCTION COST $ 51x 61DO
(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 '
e.oAc�teLW�. VA.M-1 b. BCA 106E &ACAELLA 3,18 (Os
Name of Applicant -(please print) Business Address Telephone No.
Name of Contractor and Job Foreman
Contractor's License No.
Applicant's Insurance Company
Business Address
Telephone No.
City Business License No.
Policy Number
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