0029NOTE:
With proper validation
this form constitutes an
encroachment permit
For the constructi
and other like publi
CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
public
i impr,,
DATE: :—L p- -5.7
LOCATION OF CONSTRUCTION
I
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION -'Jt/f A
DESCRIPTION OF CONSTRUCTION
private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains
ents in connection with MINOR IMPROVEMENTS and APPROVEDySUBDIVISIONS
Subdivision Improvement Permit — Class I I I
Minor Improvement Permit Class IV
-,�--
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
r /f
Sketch Ia
APPROXIMATE TIME WHEN WORK WILL BEGIN
\r
construction plans if appropriate)
APPROXIMATE TIME OF COMPLETION �\
ESTIMATED CONSTRUCTION COST $
(Including removal of all obstruction, materials, and debris, backfi'(ling, corn
paction and placing permanent resurfacing and/or replacing irr�!Krovements)
In consideration of the granting of this permit, the applicaa hereby agrees to:
Indemnify, defend and save the City, its authorized agents! officers, representatives an employees, harmless from and against any and all
penalties, liabilities or loss resulting from claims or co�rt action and arising out of any accident, loss or damage to persons or property
happening or occurring as a proximate result of any ork undertaken under the permit g-arnted 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.
Name of Applicant (please print)
Name of Contractor and Job Foreman
Contractor's License No.
Applicant's Insurance
Signature of Applicant or Agent
Business Address
Business Address
FEES: Subdivision' Improvement Permit — Class I II
Pub I/improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by w�
Recorded by ,
,Telephone No.
t�,leph one No.
City Business License No.
Policy Number
Nl c��
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
DATE ISSUED
By
Administrative Authority
TELEPHONE: (619) 564-2246