0571_ 1 rY •t i�•'. . - .,yZ-. 'Sr' . '4. y, 9 ' '�. • • ��. :.I'�'�' i !ri •� ' �. .}' , _ , i lyn i
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i *� f . , f .✓ f ... , .r', 4.4� t; qa Y 'T • 3'� t . _ r w N 1
z' 'NOTE•. , , .; «, , •t .,at,. �;,,` r, - : ,. .
With'proper.validation
thlsVo'rm constitutes an 1
i encroaclimentpermit. `? CITY�-OF LA' QUINTA "
APPLICATION -FOR PERMIT
'PUBLIC 'WORKS' -CONSTRUCTION (ENCROACHMENT)>
w*• ,
k art 4t' ' •' • T,'e A y • • r, I •
For. 'the' c'on'struction of public or
private -curbs, . driveways, pavements, sidewalks, parking lots f sewers;' water mains
:arid"other. like public•v;orks•improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
Subdivision Improvement Permit = Class 111,
DATE: �''- T �` T Minor Improvement Permit Class IV
LOCATION OF, CONSTRUCTION
(Street address or Description of,Lo
PURPOSE OF CONSTRUCTIO
tion)
` •. t
Sketch (attach, construction plans.ifIappropriate)
DESCRIPTION 0FZONSTRUCTION `
.> iII
DIMENSION,OF INSTALLATION�OR REMOVAL
SIZE.OF EXCAVATION, IF'NEEDED 10
APPROXIMATE TIME WHEN WORK WILL,BEG_IN ti
APPROXIMATE TIME OF COMPLETION'
ESTIMATED CONSTRUCTION COST $ '` •✓""�
(Including removal of all obstruction, materials, and debris,,backfill ing,„com 00518 1b. 3411 04-11. 90. `'"� 14
paction and placing permanent resurfacing. and_/or replacing improvements)) ` '� h �rt.V14 -1• Tnul• S io 0
_
In corisideratlio15 of the- granting of this permit, :the applicant hereby agrees to: i t
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,oecurring 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.
s Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules and�egulations'of.the City of - �y
La Quinta and to pay for any additional replacement .necessary as the result of this work-`. ' ` r
• ///� ;
Si -nature 4APplicant •r'Ag nt `
•Name of Applicant (please rint) .r Business Address j. Telephone No. '
Name of Contractor and Job FF000rreman . Business Address Telephone No.
'Contractor's License No. City Business`L'icense No. `t•.: ;
Applicant's -Insurance Company • ° _ .,. Policy Number
S 2,A N ,
FEES Subdivision Improvement Permit`` Class III ; f 4 `
Public improvements: 3% of estimated const uction,costs
Private improvements:” 3% of estimated construction costs , =
.
Minor Improvement Permit — Class IV: See attached schedule s '
Inspection Fee $ PERMIT VALIDATION
Permit Fee
/ PERMIT NO,
Penalty
Cash Deposit -Surety Bond DATE APPROVED T_
if required r 'EXPIRATION DATE
TOTAL: $
DATE ISSUED
Receipt No. By n
Received by Date (�%jn-istrative Authority
Recorded by / / TELEPHONE: (619) /564/2246
a
' With proper Galidation
this form constitutes an
'
CITY OF encroachment permit i ,
LA QUINTA
• • , APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
OF
For the construction of public tor private. curbs drive -la s avements std walk k' I `t
y , p e s, par Ing o at sewers, water mains
and other like public'works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
f y Subdivision•Improveinent Permit- Class III
DATE: ' i /✓ Minor Improvement Permit'Class IV
LOCATION OF CONSTRUCTION/�'/rr .~ s'//s,�✓9i�y . r�'"",f"/i,�/s�.,r���-r .
C11111111
(Street address or Description of Location) y�
PURPOSE OF CONSTRUCTION ''"�`0'� Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL&�G'�',
k -
r SIZE OF EXCAVATION, IF NEEDED "
-APPROXIMATE TIME WHEN.WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION �
�V 61
7, ,
ESTIMATED CONSTRUCTION COST $
(Including'removal of all obstruction ,'materials, -and debris, backfilling, com - _
00 51 10 •341i U4 -ti -90 14
6 6
paction and 'placing` permanent resurfacing and/or replacing improvements) A f _ _- VW 4 TnTAi - 4 10.-00 ,.
In,cansideration;of,the granting of this permit, the applicant hereby agrees to: >
Indemnify, defend and save the City, its authoriied'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 J
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 sof the permit and all applicable rules and regulations of.the City of
La'Quinta and to pay for any.aciditional replacement necessary as the result of this work•..
Signature 0-dApplicant /Agent/
Name of Applicant (please print) Business Address •- Telephone No. _• '
• Name of Contractor and Job Foreman - Business Address.• TTelephone' No.
�
Contractor''LLiicccense No."' /��/�) - City Business License No.
Applicant's`I,nsurance Company '.Policy Number.
tr ,.
FEES: Subdivision Improvement Permit - Class III t
' Public improvements: 3% of estimated construction costs
Private Improvements: 3% of estimated construction costs iQ i
Minor Impro ement•Permit - Class IV: See attached schedule`
r
Inspection Fee $ PERMIT VALIDATION
-
Permit Fee,
PERMIT NO.
t' Penalty DATE APPROVED-��� ✓�
Cash Deposit -Surety Bond /
if required r. �f/
f EXPIRATION DATE • Ff
TOTAL: , . $ `'`�y
DATE ISSUED
,. ..
• Receipt No.,
d�
- Received b - Date �0/>li �•--/C.- '"Administrative Authority
Recorded b a'
y TELEPHONE: (619) 564 22460
t -....::WWI
r
.77
NOTE: ? s
x With7propervalidation ,r —
!
s
this form constitutes an - v ` ..,• CITY, OF LA QUINTA.
encroachment permit
APPLICATION FOR PERMIT
PUBLIC WORKS• CONSTRUCTION`, (ENCROACHMENT)
• � L�oP'IAa
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: '�/ /' �d Minor.lmprovement Permit Class IV.
LOCATION OF CONSTRUCTION
(street address or Description of Location)
,, .•',`PURPOSE OF CONSTRUCTION' Sketch (attach construction plans if appropriate)
DESCRIPTIONOFCONSTRUCTION
s 'DIMENSION OF INSTALLATION OR REMOVAL'
SIZE OF EXCAVATION'; IF NEEDED, f 66.-'
• i _ w ; A
R a , APPROXIMATE TIME WHEN WORK WILL BEGIN �0
r . d® .
r ,-'APPROXIMATE TIME OF COMPLETION
�.1 a
ESTIMATED CONSTRUCTION COST $
(Including remo ' of,&11,sbs"trurtion, matifials,i and d'ebris,.b_ackfilling, com
-.:paction and placing, permanent •resurfacing and/or replacing improvements),,'
i In consideration of• the granting ,of. this- permit, .the, applicant• hereby :agrees to:
Indemnify, -defend and ,save the City, its authorized agents, officers,' representatives andemployees, harmless from and against any and all
penalties, liabilities`or,loss resulting from claims or court action•arid.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 anyadditional replacement necessary as the, result of this work.
Signature of App cant or Agent r.
:Name of Applicant (pleas rint). Business.Address r. _ 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
{ _ 4 .
FEES: Subdivision Improvement Permit - Class III ;
Public. improvements: '3%'of estimated construction costsa r
Private improvements: 3% of, estimated construction costs t . *TD
T ll
Minor Improvement Permit — Class IV: See attached schedule
r
Inspection Fee $ I .` PERMIT VALIDATION
Permit Fee t
PERMIT NO..
Penalty DATE APPROVED- '
Cash'Deposit-Surety Bond
if'required EXPIRATION DATE
TOTAL: $ DATE ISSUED
Receipt'No.
,By
Received by Date Administrative Authority.
Recorded -by r TELEPHONE: (619) 564.-2246