0063NOTE:: -
With proper validation
this form constitutes an
encroachment permit
CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
0
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 an' d}APPROVED SUBDIVISIONS
DATE: November 28,
1984 Subdivision Improvement Permit — Class II I
Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION Eisenhower Drive
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION stall 1-6" Stub—out Sketch (attach construction plans if appropriate)
connection + 600 feet west of Washinaton St. on Eisenhower Drive.
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
i. .
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
See Attached Plot Sheet.5-7-31-2
• B���XXg�X
Dist. Dwgrs..- 8913-8914
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.
Clifford Smith
Signature of Applicant or Agent
Coachella Valley Water 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
FEES: Subdivision Improvement Permit —Class III
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs j��' "
00
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
PERMIT VALIDATION
PERMIT NO. IN %A
DATE APPROVED ���✓
EXPIRATION DATE Z '�U '
DATE ISSUED'
BY -
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TELEPHONE: (619) 564-2246
I ' Administrative Authority
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NOTE:
With proper validation
this form constitutes an
encroachment permit
CITY OF LA QUINT•A
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 I I
DATE: �1 . �� �9� / �- Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PUR
DESCRIPTION OF CONSTRUCTION
DIMENSIO^: CF :-^•'•S'. ,L !_ATION OR REMOVAL
Sketch (attach construction plans if appropriate)
C
SIZE OF EXCAVATION, IF NEEDED.
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COSTS
(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, toss or damage to persons or property
happening or occurring as a proximate result of any work undertaken under the permit gra4mea rsuant to this application.
Notify the Administrative Authority at least twenty-four 124) hours in advance of the time 4w, eh k will be started.
Comply with all applicable City Ordinances, the terms and conditions of the permit and all
A.
11 151 s and regulations of the City o!
La Quinta and to a for an additional replacement necessary as the result of this.work.
pay Y P YFC n
\ W^
/7 Signat, e f Applicant \ Agent
Name of Applicant (please print) Business Address '_ Telephone No.
Name of Contractor and Job Foreman Business Address
k
`” '' r Telephone No.
Contractor's License No. Cit "B"Usiness icense No.
Applicant's Insurance CompanyPoltcy Number