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0025NOTE: With proper validation this form constitutes an encroachment permit t 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 I I DATE:,-�,r�f �cl�,.� 4 �'• 1�� 1Minor Improvement'Permit "Class IV /l f s"} ! P.r•:.J��st •'.,po'R LOCATION OF CONSTRUCTION ,•.,�_..,,..,�,-..,.,,,�%,,� - r (Street address or Description of Location) .y PURPOSE OF.CONSTRUCTI,ON r, X 6k . afP 1�. �r�! r �S2.es► .-•CA[� DESCRIPTION OF CONSTRUCTION DIMENSION OF INSTALLATION OR REMOVAL SIZE OF EXCAVATION, IF NEEDED APPROXIMATE TIME WHEN WORK WILL BEGIN Sketch (attach construction plans if appropriate) :' 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 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 vw4b Name of Applicant (please print) Business Address Name of Contractor and Job Foreman Business Address Contractor's License No. Telephone No. Telephone No. City Business License No. Applicant's Insurance Company Policy Number FEES: Subdivision Imorovement Permit — Class I I I Public improvements: 3% of estimated construction costs Private improvements: 3% of estimated construction costs Minor Improvement Permit = Class IV: See attached schedule Inspection Fee $ ✓ % A�� Permit Fee Penalty Cash Deposit -Surety Bond if required TOTAL: $ Receipt No. Received by Date Recorded by PERMIT VALIDATION PERMIT NO. ell `r DATE APPROVED /` '' ,22, 'Inf X' EXPIRATION DATE./ 226 DATE ISSUED f `f�=�'� By Administrative Authority TELEPHONE: (619) 564-2246 NOTE: �^ With proper validation tl,i,s form constitutes an encroachment permit RECEIVE® .IAN 3 ©1983 City of La Q�ri �� 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 III DATE: o Minor Improvement Pe it Class IV LOCATION OF CONSTRUCTION (Street address or Description of Location) 4 DIMENSION CF==.:^•'•ST.-,L LATION OR REMOVAL SIZE OF EXCAVATION, IF NEEDED APPROXIMATE TIME WHEN WORK WILL BEGIN Sketch (attach construction plans if appropriate) 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: ( 41 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 thi$ work. _.,9iWature of Appiicant o Agent Name of Applicant (please print) Business Address Telephone No. Name of Contractor and Job Foreman Business Address Telephone No. Contractor's License No. Applicant's Insurance Company City Business License No. iPoficy Nurpbell �t�j �. w tCt���..r� ..a ►. r '�c.lir t, .`�f,, x_. r : � :. �.s i;�47i or T 77 _7 - I ,&I , I �, � !�,I a� 4-4,-Z4 o 4 o A ttt t i,� j-, V, ,&I , I �, � !�,I 1-1 -li- It 11 o 4 o A ttt t i,� v ."j 7, It,*-�" tit o� V, '4 �4 J, 'P. 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'�ERN61N IMPRO lleWtNr,�� -RI &V.6 4V 4 t R\) J FDAVI DSONASSOCIATESit,� rY L4 APPROVED B �7 R 'EYORS I'PLANNERS CML ENGNEERS So % REGIST0E()LCIVL ENGINE P N T N V E: 0, 7 825 C/ry 0,4 Liq SCALE -0 By': BENCH MARK WE T 1� 1 1 `L- t�' ( , , ,4" , , ',' ; "� j , ' L. IV t A 7 F A7.5 rk #0 R, v o rep SEIE. - - 5H EE ?r - V Vt� "V If" el 7- y clvr, NEER DATE r Vi % y X it FOR jQVV6)V Cozvoxq r/d jv `,DATE,� Ive. r -V �1, I- m 4:4 -co CO. .0 r m, "i- Nur, V "'s ry 1/c no �I 7 $ J, 4 1 t,� A, . ­ I J�� I .1p -�`,- t A—L 1.1, 1 1, , ­;g­� jr 4� ittA.4- u AV& ;�4 1-1.�Wl tt.,! ma -,4—# A".. it - 11 o 4 o A ttt t i,� v ."j 7, It,*-�" tit o� V, '4 �4 J, 'P. 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'�ERN61N IMPRO lleWtNr,�� -RI &V.6 4V 4 t R\) J FDAVI DSONASSOCIATESit,� rY L4 APPROVED B �7 R 'EYORS I'PLANNERS CML ENGNEERS So % REGIST0E()LCIVL ENGINE P N T N V E: 0, 7 825 C/ry 0,4 Liq SCALE -0 By': BENCH MARK WE T 1� 1 1 `L- t�' ( , , ,4" , , ',' ; "� j , ' L. IV t A 7 F A7.5 rk #0 R, v o rep SEIE. - - 5H EE ?r - V Vt� "V If" el 7- y clvr, NEER DATE r Vi % y X it FOR jQVV6)V Cozvoxq r/d jv `,DATE,� Ive. r -V �1, I- m 4:4 -co CO. .0 r m, "i- Nur, V "'s ry 1/c no �I 7 $ J, 4 1 t,� A, . ­ I J�� I .1p -�`,- t A—L 1.1, 1 1, , ­;g­� jr 4� ittA.4- u AV& ;�4 1-1.�Wl tt.,! ma -,4—# A".. it - 11 o A ttt t i,� v ."j 7, It,*-�" tit o� V, '4 �4 J, 'P. 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'�ERN61N IMPRO lleWtNr,�� -RI &V.6 4V 4 t R\) J FDAVI DSONASSOCIATESit,� rY L4 APPROVED B �7 R 'EYORS I'PLANNERS CML ENGNEERS So % REGIST0E()LCIVL ENGINE P N T N V E: 0, 7 825 C/ry 0,4 Liq SCALE -0 By': BENCH MARK WE T 1� 1 1 `L- t�' ( , , ,4" , , ',' ; "� j , ' L. IV t A 7 F A7.5 rk #0 R, v o rep SEIE. - - 5H EE ?r - V Vt� "V If" el 7- y clvr, NEER DATE r Vi % y X it FOR jQVV6)V Cozvoxq r/d jv `,DATE,� Ive. r -V �1, I- m 4:4 -co CO. .0 r m, "i- Nur, V "'s ry 1/c no �I 7 $ J, 4 1 t,� A, . ­ I J�� I .1p -�`,- t A—L 1.1, 1 1, , ­;g­� jr 4� ittA.4- u AV& ;�4 1-1.�Wl tt.,! ma -,4—# A".. it - 11