0036NOTE:
With proper validation
this form constitutes an
encroachment permit CITY OF LA OUINTA
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:.�'�
LOCATION OF CONSTRUCTION'��
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION
DESCRIPTION OF CONSTRUCTION
DIMENSIOVOF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
Subdivision Improvement Permit —Class II I
Minor Improvement Permit Class IV
APPROXIMATE TIME OF COMPLETION - �"OS/,•Cf�'..
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 result of this work.
Nse- "X6�/_
,Name of Applicant (please print)
Name of Contractor and Job Foreman
Contractor's License No.
�j
`Signature of Applicant or Agent
Business Address
Business Address
Telephone No.
Telephone No.
City Business License No,
Applicant's Insurance Company Policy Number
FEES: Subdivision -Improvement Permit — Class II 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 $
DATE APPROVED'�'�+�'`�'
Permit Fee
EXPIRATION DATE�'���
Penalty
`
Cash Deposit -Surety Bond
if required
�a
"
TOTAL:
Receipt No.
Received by Date. 45; 'l '
Recorded by `
N9 136
PERMIT VALIDATION
PERMIT NO. "45,
DATE APPROVED'�'�+�'`�'
EXPIRATION DATE�'���
DATE ISSUED
"
177—
'—
Jr�Y Administrative Authority
TELEPHONE: (619) 564-2246