0023NOTE:
With proper Zidation
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 .
DATE: `-
.LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION
' DESCRIPTION OF CONSTRUCTION'
Subdivision Improvement Permit — Class III
Minor Improvement Permit Class IV
Sketch (attach construction plans if appropriate)
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
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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.
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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 Wi's;work.. '
/�,Signature`of Applicant or Agent
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. t
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 — Clasps IV: See attached schedule
Inspection Fee $ `>'a PERMIT VALIDATION
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Permit Fee PERMIT NO. /15 1 �'
.Penalty.C;��,�!' rd7�'�' '• ` ,,�•�,/r s �t'�
Cash Deposit Surety Bond DATE APPROVED
if required EXPIRATION DATE
4TOTAL: $ a P1S i s Gam%
DATE ISSUED
Receipt No. 1'�/
Received by Date / Administrative Authority
Recorded by TELEPHONE: (619) 564-2246
O
NOTE:
With proper validation
•
this form constitutes an`v
encroachment permit CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT) `
OF TRF
For the construction of public or private curbs; driveways, pavementsi sidewalks, parking lots, sewers, water mains
and other like publictworks..improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
Subdivision Improvement Permit — Class III
DATE: 1 inor Improvement Permit Class IV
LOCATION OF CON STRUCTIO
�—
(Street address or Description of Location)
PURPOSE OF CONS UCTION
04 J
DESCRIPTION OF'CONSTRUCTION
LIJ�G./C
DIMENSIO^: CF I"IST.',LLATION OR REMOVAL
T
SIZE OF'EXCAVATION, IF NEEDED
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APPROXIMATE TIME WHEEGINri
APPROXIMATE TIME OF OMPLETION
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.
i'
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.
Name of Applicant (please print)
Signature of Applicant or Aunt
Business Address
J Telephone No.
fame of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No. City Business License No.
App it cant's Insurance Company Policy Number -
FEES: ; Subdivision Improvement Permit — Class III
Public improvements: 3% of estimated construction costs
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