0593` .NOTE: • .. , , „ - : � r t :. � ' :�'
With proper validation I 2
O
this form constitutes an CITY Of LA' QUINTA • "
encroachment permit.
APPLICATION FOR PERMIT -
PUBLI,C WORKS.CONSTRUCTION'_(ENCROACHMENT)
. OF IFiB��S
,. ,
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 IJ 1
DATE: Minor Improvement Permit Class IV '
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
` PURPOSEOF CONSTRUCTION Sketch (attach construction plans if appropriate)
-DESCRIPTION OF CONSTRUCTION-
DIMENSION
ONSTRUCTIONDIMENSION OF INSTALLATION•OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $ '
(Including removal of'all obstruction, materials, and debris, b fillip , co
paction and•placing;permanent'resurfacing and/or4repl improve n )
In consideration •of the+granting of this permit, the pp 'can hereby, agrees'to:
Indemnify, defend and save'the City, its authorize'agents, offic rs, representatives and employees, harmless from and against 'any•and all
`
penalties,- liabilities -or loss resulting from claims r.court' a tion nd arising out of, any accident; 'loss or' damage to persons,or property
happening or -occurring as a proximate result, of ny work un erta en under the permit granted pursuant to this application. ' y
• Notify the Administrative Authority at least t e9ty-four,(24) h r in'advance of the time when work will be -started.-, w
Comply with all -applicable City Ordinances, t terms and conditions of the permit and all applicable -rules and regulations of.the City of �.
La.Quinta•and to -pay for^any dditional replacem t necessary as :the result of this work. '
_ Signature of Applicant or Agent
Name of Applicant (please print) ' r 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 III
'Public improvements: 3% of estimated construction costs
Private improvements: 3%,of estimated construction costs.
N* 0-5,91.
..Minor'[mprov,ement Permit— Class IV: See attached schedule
.1V
•Inspectio.n Fee • • $ " 1
PERMIT VALIDATION -
Permit Fee
,. r
x'
PERMIT NO. '
t '
•I
Penatty .. ,�.•
H
y'
Cash Deposit Surety Bond
i'
DATE,APPROVED'
if required
EXPIRATION DATE `
TOTAL: $
-DATE
ISSUED `
:
Receipt No.:,,♦
,
By '
' Received,by Date �'
Administrative Authority
Recorded by
TELEPHONE:-' (6.19) 564-2246
NOTE: i r
With proper validation 4 2
this form constitutes an
encroachment permit CITY OF LAQUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT).��
OP
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
r Subdivision Improvement Permit — Class III
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION i
DIMENSION OF INSTALLATION OR 136MOVAL
SIZE OF EXCAVATION, IF NEEDED `
L. APPROXIMATE, TIME WHEN WORK WILL BEOfV^ F
'APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $
(Including removal of al l' obstruction, materials, and debri,b ckfilling comb ,
paction,and placing permanent resurfacing aA/or repla: n,g improveme�nt� )
mow,'...
In consideration of the'granting, of. this, permrf;;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
-c
b
penalties, liabilities or loss resulting.from claims or court a t on and arising out of any accident, loss'or damage to persons ci 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) hou�r�s in advance of the .time when'work will be started.„
Comply with- all applicablet'City Ordinances, he terms and conditions of the permit and all applicable rules and regulations of theCityof
La Quinta"and to pay for,any dd�iitional replacement necessary as the result,of this work.• R
•- Signature of Applicant or Agent„
w4Name 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.
i
Applicant's Insurance Company. Policy Number y
FEES: Subdivision Improvement Permit — Class I I I.
Public improvements: 3% of estimated construction costs..
Private improvements: 3% of estimated construction costs;
KTO
IN -.0503
Minor Improvement Permit - Class IV,: See attached schedule_
A.
Inspection. Fee $ PERMIT VALIDATION t'
Perm itw Fee PERMIT NO.
x Penalty DATE APPROVED
Cash Deposit -Surety Bond
if required EXPIRATION DATE
` TOTAL: $ +-DATE ISSUED
r
Receipt No.
By
Received by Date Administrative Authority
Recorded by TELEPHONE: (619) 564-2246
� . r• r�_Tj�:l'YV'1rJ?.1.,4..w r' ;< :.0 dm f:r;:,.,�/+ti.d:
n .
NOTE:
With proper validation
this form constitutes an CITY OF LA QUINTA
encroachment permit
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 I I I
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION 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
"ESTIMATED CONSTRUCTION COST $
(Including removal of all obstruction, materials, and debris backfilling, com,
paction and placing permanent resurfacing and/or repla"cing improvements)
In consideration of the granting of this permit, the applicanthereby agrees to:
Indemnify,;defend.an.d save the City, its authorized agents officers,•rep resentatives 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 bny 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 thejCity of
La Quinta and to pay for any additional replacement necessary 'as the result of this work.
Signature of Applicant or 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 i
Private improvements: 3% of estimated construction costs- 0
(Dir 3
Minor Improvement Permit - Class IV: See attached schedule,
e9
Inspection Fee $+ / II PERMIT VALIDATION
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $
Receipt No.
Received by Date
Recorded by
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
TELEPHONE: (619) 564-2246
Administrative Authority