0285 (2)NOT
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
1 Subdivision Improvement Permit— Class III
DATE: `� �' 11" Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 0/� ' �' tr' �9 ; j4 4 / * i �' �4• �'.�• i— '�
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION
DESCRIPTION OF CONSTRUCTION
.",, Z,.1 -„,, 'r-. i.✓r• .'I.:7/%ILL 144.r/
•1r. ; A/:: 7 'r
DIMENSION OF INSTALLATION OR REMOVAL
Sketch (attach construction plans if appropriate)
off,
72.
SIZE OF EXCAVATION, IF NEEDED
fw
APPROXIMATE TIME WHEN WORK WILL BEGIN,
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $ /• �' O t'
(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•wo{k undertaken under the permit granted pursuant to this application.
Notify the Administrative Authority at least twenty(l=foils (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 gf this work.
Signature of App�i,c�any r Agent
/ !
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 I II
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $ �. o
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $
Receipt No.
Received by ` — Date
Recorded by
RD -31
IkT r-- 2
1L .
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE //z/ IJ -2
DATE ISSUEDBy
Administdtive Authority
TELEPHONE: (619) 564-2246
be replaced by a licensed civil engineer or surveyor at the expense of the permittee. A complete set of notes showing the
ties to these monuments shall be furnished to the City Engineer prior to the removal of any monuments. This office shall
be notified upon completion of replacement of all survey monuments for proper project clearance.