0098NOTE:
With proper validation
this form constitutes an CITY OF LA QUINTA
encroachment 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 III _1110,
—
DATE:. I
��. + Minor Improvement Permit Class IV
PAR LOCATION OF CONSTRUCTION .S� t��i+�iG I%% �%//�' '�--
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION ol9- 9 -IMC -P— /.us7: Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION"-+
DIMENSION OF INSTALLATION OR REMOVAL �5
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:
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.
t '
Name of Applicant (please print)
Signature of Applicant or Agent__
Dolt_ A
Business Address �? ` . Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
. / 39,E 6,c .r.
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
Me" ;98
PERMIT VALIDATION
PERMIT NO.'—
DATE
O.• DATE APPROVED
EXPIRATION DATE
DATE ISSU
By
TELEPHONE: (619) 564-2246
Adm'inistfative Authority
Inspection Fee $
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
� cq
TOTAL: $
v0a
Receipt No.
Received by
Date
Recorded by
Me" ;98
PERMIT VALIDATION
PERMIT NO.'—
DATE
O.• DATE APPROVED
EXPIRATION DATE
DATE ISSU
By
TELEPHONE: (619) 564-2246
Adm'inistfative Authority