0603 (2)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
r and other like public works improvements in connection'with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
49� --- 3
Subdivision Improvement Permit — Class III -
DATE: �+�^ 3 Minor Improvement Permit Class IV
LOCATION OF—CONS- RUCTIO
W e4S � 7-0 IO/ ,
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTAL -L- TION-E)R REMOVAL
of /9 / r •
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, corn-,
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 wiii•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. i
J rig.,'. -(L (11.• - ,
s f SivV,gnature of Applicant or Agent QJ417,S F
Name of Applicant (please print) Business Address Telephone. No.
Name of Contractor and Job Foreman Buslness`Address��w'telephone No.:,,
Contractor's License No: City, Business: License No.
Applicant's Insurance Company ' , s:. Policy Number
FEES: Subdivision Improvement'Permit —ba' ss•ll l . td� ;`'.• ��..r' `�; � .{. �� '
Public improvements: 3% of estimated construction costs'
Private improvements: 3% of estimated construction costs NO
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $ -4 PERMIT VALIDATION
Permit Fee I.
PERMIT NO.
Penalty
Cash Deposit -Surety Bond DATE APPROVED
if required EXPIRATION,DATE
TOTAL: $ DATE ISSUED,
Receipt No.,
By
Received by Date Administrative Authority
Recorded by TELEPHONE: (619) 564-2246