0125r490TE
With proper validation
this form constitutes an
encroachment permit CITY OF LA QUINTA k
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)��
'SOF TN89
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: / / /� `/ �. / �'� Subdivision Improvement Permit — Class III --��
A
J�.. '7Minor Improvement Permit Class IV LOCATION OF CONSTRUCTION 145FALIM 1-ar? AA/sXA
(Street address or Description of Location) w
PURPOSE OF CONSTRUCTION -S %? AP/?pdi ?Sketch (attach constructionfans if a '
p ppropriate) -
DESCRIPTION OF CONSTRUCTION C'. ���✓� 1
DIMENSION OF INSTALLATION OR REMOVAL A>Ll/V6 {
SIZE OF EXCAVATION,.IF NEEDED A '
APPROXIMATE TIME WHEN WORK WILL BEGIN
. ter• .
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.
Signage of Applicant or Agent
Ad
Name of Applicant (please print) Business Address Telephone No..
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No. M City..Busihess 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
G
Inspection Fee' $ �� m PERMIT VALIDATION
b '
Permit Fee • S� '� ��'� ,
PERMIT NO.
Penalty
Cash Deposit -Surety Bond DATE APPROVED
if required
E / D
00, EXPIRATION DATE �/
4 TOTAL: $ A7 ` — DATE ISSUED , ds
Receipt No.
By.
Received by Date Administrative Authority
Recorded by TELEPHONE: (619) 564 2246 f