0024NOTE:
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 II I
DATE: �/� ~ __'> L L ? Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION s�'.?//�,L1/al` C.L�/"_0/1 Vii°,
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION
RIPTION OF CONSTRU
DIMENSION C+F, INSTALLATION OR REMOV
SIZE OF EXCAVATION, IF NEEDED��'
Sketch (attach constructionlans if a
p pproppiate)
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $ Oro
i
(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 Applicant or Agent
NaTF of Applicant (please print) Business Address 1 Telephone No.
n w
' ZJ
;me of tontractor and Jo oreman
Contractor's License 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 $ 'LlP"'
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required e
TOTAL: $
Receipt No. .7 , ,,,
A.
Received by e''- /��"""Date
Recorded by `� t
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
B y �
Administrative Authority
TELEPHONE: (619) 564-2246
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
DATE: _Ce -2 � WAfV Com'
LOCATION.OF CONSTRUCTION _
(Street address or Description of Location)
PURPOSE OF CONS RUCTION
I/SSFNf
DE IFN OF PONSTR CTI N.
,,�� �4 �J-L AS
DIMENSION OF Ir9STALLATION�OR REMOVAL
2 /-om r
-1 tA ^— n rr—LL n .
Subdivision Improvement Permit — Class III
Minor Improvement Permit Class IV
S
4
,E Sketch (attach construction plans if appropriate).
59=A,01
L FF-F&C- 1 AP"WE0
pox srn-ar Ft . -
SIZE OF EXCAVATION, IF NEEDED A LbA) —
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION Is 0_q
ESTIMATED CONSTRUCTION COST $ -- 6Zx2i - 20
(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 Applic nt or A nt
C24AIMLIL-A coo<MAI 64 7 gds'^667,5
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.
APPllaant s Insurance Company Policy Number