0543 (3)NOTE:
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
/ Subdivision Improvement Permit -Class III
DATE: V 2 f Minor. Improvement Permit Class IV
LOCATION OF CONSTRUCTION - L ' Q 7 L 01W 71 AGi 1,3 g 7
(Street address or Description of Location)
,-PURPOSE OF CONSTRUCTION �(C CC - - PA"Ur Q- Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED.
APPROXIMATE TIME WHEN WORK WILL.BEGIN
APPROXIMATE TIME OF COMPLETION YZ
,,ESTIMATED CONSTRUCTION COSTS »�
(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 Quint@ and to pay for any additional replacement necessary as the result of this rk.
U ,Q /-4 P S (4 0 13 4cl- ►L( K_ Signature of Applicant or Agent
„f P CLt-k 'beSARC'ASo(/ doki6T, dods.ccRe-t
Name of Applicant (please print) Business Address Telephone No.
R &A e-,5 R. U e if dI ",57-41V C11 0 >< I 411-4j-( eg R PO RATc G% A V S 8 - Sfl e -0
Name of Contractor and Job Foreman Business Address, Telephone No..
Contractor's License No. City Business License No.
A11;at:),l LSP // h 6 a,�
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit - Class. 111
Public improvements: 3% of estimated construction costs JJ
Private improvements: 3% of estimated construction costs
Minor Improvement Permit - Class IV: See attached schedule
Inspection Fee $
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $
Receipt No.
Received by Date
Recorded by
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
TELEPHONE- (6191564-2246