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0031NOTE: Vii. • • With proper validation this fora 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 ,(Subdivision Improvement Permit —Class I II DATE: �%'G'// �i�� Minor Improvement Permit Class IV LOCATION OF CONSTRUCTION-4Ue/1✓w-E? 4-© /_ � n r„r/ A, e� (Street address or Description of Location) PURPOSE OF CONSTRUCTION DESCRIPTION OF CONSTRUCTION DIMENSION OF INSTALLATION OR REMOVAL SIZE OF EXCAVATION, IF NEEDED 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: 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 re3ul•t o•E this work. n 1911 Name of Applicant (please print) Signature of Applica t or Agent Business Address Telephone No. Name of Contractor and Job Foreman Business Address Telephone No. Contractor's License 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 Permit Fee Penalty Cash Deposit -Surety Bond if required TOTAL: Receipt No. Received by Recorded by $�, do ,r $ Date 0 PERMIT VALIDATION PERMIT NO. DATE APPROVED t EXPIRATION DATE. DATE ISSUED By Administrative Authority TELEPHONE: (619) 564-2246 tNOTE: With proper•validation _'•.'this forrr,.1�`,'° nstitutes an encroachJfnent 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 III DATE: MARCH 5, 1984 Minor Improvement Permit Class IV LOCATION OF CONSTRUCTION 78-255 AVENUE 50 LA QUINTA, CA. (Street address or Description of Location) PURPOCSFIE OF CONSTRUCTION Instal 1 and maintain a ONE Sketch (attach construction plans if appropriate) (.1') domestic water service DESCRIPTION OF CONSTRUCTION DIMENSION OF'INSTALLATION OR REMOVAL SUZE OF EXCAVATION, IF NEEDED APPROXIMATE TIME WHEN WORK WILL BEGIN CEIV FED MAR 7 '►984 city of La r 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 f this work. -4, _ gnature of Applicant YAgent Coachella Valley Water District P. 0. Box 1058 Coachella, Ca. 922.36 (.619) 398-2651 Name of Applicant (please print) Business Address Telephone No. Name of Contractor and Job Foreman 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 $ Permit Fee _ Penalty _ Cash Deposit -Surety Bond if required _ TOTAL: Receipt No. _ Received by Recorded by Date N° PERMIT VALIDATION - PERMIT'NO. ©�Z — DATE APPROVED EXPIRATION DATE DATE ISSUED By TELEPHONE: (619) 564-2246 Administrative Authority r) rn w D z W I UIJIEI/IUOLUdoia Plutno Ar9(j lfl!unLuLuoo el 10 j%3 (ISAOtid dV ui -44 ;W5 Oe '02 12 UIJIEI/IUOLUdoia Plutno Ar9(j lfl!unLuLuoo el 10 j%3 (ISAOtid dV IN