0066NOTE:
With pro -Ar validation
this form constitutes an CITY OF LA QUINTA
encroa,:hment 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 II I
DATE: I7Pcttmmbizr 1.3; 1.984 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION Washington Strep+ and T -T n;, 1 1 1
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Install 1-12" Stub -Out
connection at Hwy 111 and Washington Street
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)
See Attached Drawings
Plat Sheet 5-7-19-2
Dist. Dwgs. 11886-11887
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
CoarhPlla Val.lev Water Dist. P.O. Box 1058 C.V. 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
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $
Permit Fee f`� (W -,,Q ,
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by
Date
N9 rt1166
PERMIT VALIDATION
PERMIT N0.'
DATE APPROVED IRI
(' 8
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
Recorded by 11 TELEPHONE: (619) 564-2246
NOPE:
With proper 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
DATE:
LOCATIO
(Street address or D
PURPOS
DIMENSIO": CF !NST. ,L !_ATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
Subdivision Improvement Permit•— Class III
Minor Improvement Permit Class IV
Sketch (attach construction plans if appropriate)
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, representative's and employees, harmless from and against any and al!
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 os,
La Quinta and to pay for any additional replacement necessary as the result of this work.
ignat of Applica or Agent
Name of Applicant (please rint) Business Address Telephone Na.
Name of Contractor and Job Foreman
Contractor's License No.
Business Address Telephone No,
City Business License No.
Applicant's Insurance Company Policy Number
I