0107 (2){ ^ it �,,�y �' ` � . • �,, tea '" ',
NOTE:~
With proper validation 4 Q
this form constitutes an ' • .-
C1TY•_OF LA QUINTA,.
encroachment permit !
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
OF$��'
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 '
5 Subdivision Improvement Permit — Class III
DATE: Aoril 11. 1985 Minor Improvement•Permit Class IV
LOCATION OF CONSTRUCTION Corner of Fi4enht7wer and Washinai!6n
(Street address or. Description of Location)
PURPOSE OF CONSTRUCTION TO Install Cable Tines Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION TOtal trench and
street'cuts 392' each EM FLANS •!
,
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN �r �� Ia', 85
APPROXIMATE'.TIME OF COMPLETION ���, Qq 19c�'�
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:
.I ndemnify,•defend and save the• City, its .authorized agents, officers, representatives and employees, harmless from and against any and all.
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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 toithis application.
the
Notify the Administrative Authority at least twenty-four (24) hours in advance of the time when work will started.
Comply with all applicable City Ordinances, the terms and conditions ofrthe permit'and all applicable' rules and regulation's of the City of
La .Quinta and to:.pay for any additional replacement necessary as the result f this work.
ature. of Applicant or Agent
' _ C.V4T.Vv 74-175 El Paseo 40!•Box 368• Palm Besert,-CA 56870140•
k,
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
Contractors License No. City Business License No.
1
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 •@�ra�`
'
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $/ PERMIT VALIDATION
�-. 1i (� j
Permit Fee' '/ "��
- PERMIT NO. • ``a�
Penalty
11 Ic�rJ
r a
Cash Deposit-SuretyBond DATE APPROVED .3 l
`
if required EXPIRATION DATE q(1 15 r'`
TOTAL: $
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DATE ISSUED I ►
'
Receipt No. 5
By
Received by "Date Administ'rative'Authority
Recorded by .TELEPHONE: (619) 564-2246-