0032'NOTE:
With proper validation
this form constitutes an
encroachment permit
0
46
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
,� /� �y/��f Subdivision Improvement Permit — Class I I I
DATE: / 7 ,5Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION /lP�N// /�' o.T//.�oP17 /�.a' 1�i+r�)�!"�` /f�i<'%��ngA -,.07
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION C7�11 A"> A' 7P4 7',07" 9 M ,�.ne
/
DESCRIPTION OF CONSTRUCTION ,f'OM,924! -0Yia 12^4 Al'. 26°;
405 ' o" e 4 y ii i(✓ f` � C. �s /"
DIMENSION OF INSTALLATION OR REMOVAL Af A416-7
SIZE OF EXCAVATION, IF NEEDED A114
APPROXIMATE TIME WHEN WORK WILL BEGIN �/X,-- Z!5r*
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:
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
tarted^Comply with all applicable City Ordinances, the terms and conditions of the perr9-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)
of Applicant 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 r
132
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
/,-11 10 %"_
Date
PERMIT VALIDATION
PERMIT NO. ^ _--� _�2_
DATE APPROVED '»,IAa A 4'
EXPIRATION DATE '1
DATE ISSUED
Administrative Authority
TELEPHONE: (619) 564-2246
.jA-ptJN1 MOTEL • LANDMARK
CA QUIP' CALIFORNIA
' DETACH AND RETAIN THIS STATEMENT
T ATTACHED CHECK IS IN PAYMENT OF ITEMS DESCRIBED BELOW.
I ORRECT PLEASE NOTIFY US PROMPTLY. NO RECEIPT DESIRIM
017112
-.1 N, O 1 C E
D E S C R I PT 1 0 TOTAL .
7 AMOUNT
DISCOUNT
NET
NET
.•' DATE
NO.
3/28
Encroachment Permit
$398.32
Ave 50 boiaz LaQuinta Project