0060':
NOTۥ:.
Wiproper validation
this form constitutes an
encroachment 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
November 15 19$4 Subdivision Improvement Permit —Class II I
,
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION Washington Street, Ave. 50 and Calle Norte
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Install 2 —12" stub—Out
Qenema*ion S
DESCRIPTION OF CONSTRUCTION mnnmrtion
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
Sketch (attach construction plans if appropriate)
See attached copies of plot sheet.
6-7-62 and Dist Dwg. 11945
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
Cnar1+P11a 17a11Pv wahex District P.O. Box 1058 398-2651
Name of Applicant (please print) 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..
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FEES: Subdivision Improvement Permit — Class III I
Public improvements: 3% of estimated construction costs
.Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
N19) 60
Inspection Fee
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No. .
Received by
Recorded by
(1n a
U
$ 1I
Date .
PERMIT VALIDATION
PERMIT NO. n'
i
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
- Administrative Authority
TELEPHONE: (619) 564-2246
1�, r,
NOTE:
With proper validation
this form constitutes an
encroachment permit
�41
RECEIVED
Nay ' 1984 --
IN_T�A CITY OF LA QUINTA
CttY OGp %T "— COMMUNITY.DEVELOPMENT DEPT
B°t�p1N 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
A
DATE: '�-
Subdivision Improvement Permit — Class III
Minor Improvement Permit Class IV
PURP OF CONSTRU TIO p� ��-�� �`` �a �� Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION
DIMENSION CF 1MST:',LLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
4,117
�����/ ✓lbw"v�
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $ T
(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.
,f
�ignatur Applican or Agent
Name of Applica�it (please print) 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
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