0091NOTE: -
With proper val
this form const
encroachment I
For the construction of public or, private curbs driveways, pavements, ents, sidewalks, parking lots, sewers, water mains
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
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s an CITY OF. LA QUINTA '
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APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
qq Subdivision Improvement Permit — Class) I I
DATE': - ` -V_ Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION, L�iSe��GTcK/ ��; ��/���///� I
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION /?'%
-DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
Sketch'(attach construction plans if appropriate)
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN A"A _e,,4 :5`
APPROXIMATE TIME OF COMPLETION 9;�
ESTIMATED CONSTRUCTION COST $ M
(Including removal of all obstruction, materials, and debris, backfilling, com-
paction andlacin
p g permanent resurfacing and/or replacing improvements)
In consideration of the granting of this permit, thecapplicant hereby agrees to:
Indemnify, -defend and save the City, its authorized agents, officers, representatives and employees, harmless from and against any and all m
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
Name of Applicant (please print) Business'Address Telephone No' '
Air
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 I I I
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs I "' A
Minor Improvement Permit — Class IV: See attached schedule N11 09�
Inspection Fee $ �... �'J PERMIT VALIDATION
Permit Fee
PERMIT NO. -
Penalty �^ r
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
$
Received by Dag
Recorded by
DATE APPROVED
EXPIRATION DATE
40 __—
DATE ISSUED 2, ���
r
By
,✓ Administrative Authority
TELEPHONE: (619) 564-2246 \-