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0622NOTE: / t 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 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 ; r APPROXIMATE TIME OF COMPLETION ' •' ESTIMATED CONSTRUCTION COST $ R (Including removal of all obstruction, materials,.and debris, backfilling; com- paction om paction and *placing -permanent resurfacing and/or replacing -improvements) In consideration. of the granting of this permit, the applicant hereby agrees to: ' 4-• {,� Indemnify, -defend and save the City, its authorized agents, officers, representatives and employees,'hatrimleis 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 Quinta and topay for any additional replacement necessary. as the result of this work.. ' y Signature of Applicant or Agent .` Name of Applicant. (please print) Business Address Telephone No. Name of Contractor and Job Foreman Business Address Telephone No. ContractoKs License No. 4 . City Business License No. . Applicant's Insurance Company- Policy Number FEES- Subdivision Improvement'Permit — Class III , t, ' Public improvements: 3% of estimated construction costs Private improvements:, 3% of estimated construction costs N2' 2 0 6 2 2 , Minor Improvement Permit — Class IV: See attached schedule Inspection Fee $ PERMIT VALIDATION Permit Fee 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 dy TELEPHONE: (619) 564-2246 t NOTE: " 'With proper validation • 2 this form constitutes an encroachment permit CITY OF LA QUINTA APPLICATION ''FOR PERMIT # PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)�� '' tiSw�ti SOF II38� '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: 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 y SIZE OF EXCAVATION, IF NEEDED a 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 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 ofany 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. i h Comply, with all applicable City Ordinances, the terms and conditions of the `perniit and all applicable rules and regulations of the C•itY o f 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. Applicants 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 A� o ' Minor Improvement Permit — Class IV: See attached schedule 1V- •0.6 2 Inspection Fee PERMIT VALIDATION Permit Fee 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 '` NOTE''` ' With proper validation ' , tk;c form ,,,ctit^ac"" E K���� ��F ��` K�QUyN�^ u,nuuh��r� � ' � . T APPLICATION ,FOR PERMIT . PUBLIC WORKS CONSTRUCTION (ENCROACHMENT), . . . . ~�L0����, . ' For the cong�uotinn of public or -private curbs, 'driveways, pavements, sidewalks, parking lots, sewers, wmto,.mains ' . ' and other like public works improvements in connection with MINOR -IMPROVEMENTS and APPROVED SUBDIVISIONS Subdivision |mprovomontPo,mit—Clao U| --_---__—_ ' ^ ^ DATE: ' ' ` [Nino, Improvement Permit Class |V ' LOCATION � _^ . ^ . ' (Street address myesc,'nuonmLocation) , . PU'pOSE OF CONSTRUCTION ^ ' ' Sketch (attach construction plans ifappropriate) . — . D6SC�R|PT0N, OFUCT|ON .^ _ ' ' [ |K8ENS|ON OF INSTALLATION OR REMOVAL ` + _— ' SIZE OFEXCAVAT|ON.|FNEEDED ' , APPROXIMATE TIME xvHEmVVOxKvx|LLBEGIN . ' ' ^ .*prnVX/ww./E //xxEuF_CuwrLE//um ESTIMATED CONSTRUCTION COST $ (Including removal nfall ubstruoton'n`ata,ia|s'and debris, backfilling, oon- �_pucb6n and placing permanent resurfacing and/or replacing improvements) In ,ohsido,ati6n of the granting: of this permit, the -applicant hereby ugmo to: � . ' �m � '/nuomn�v'�e�nu and save the City, �authorized agents, officers,officers,mpm,e�a�ve and emnx*m '�x^�xea,mavuauu� m unwl ^ mes, |iam/uxw or loss resulting from c/a/ns or court action and arising out of �* accident,/ma�x uoma�,n nx�on or property' happening or vc9u,,/nn as u proximate result m any work undertaken under me'nnnnit om6mu pursuant to this application.' ' ' . ' Notify the Administrative Aumunm at least twenty-four (2*) hours in advance of moltime,when' Work will be started. umnnly with all applicable City Ordinances, 'the terms and conditions mthe permit and all applicable rules and regulations m,mvCity m Lu omimm and to nay' for any ,uumonai replacement necessary as the msu|t'm this work. Signature of Applicaht or Agent Name of Applicant (plea se print) Business Addre s s Telephone, No...,: Name of Contractor and Job Foreman Business Address Telephone No. Contractor's License No. City Business License No. Applican't's Insi6rance Company Policy Number FEES: Subdivision Improvement Pirmit,� Class III Public improvements: 3% of 6timated construction costs, Private improvements: 3% of estimated construction costs Mino� Improvement Permit'— Class IV: See attached schedule Inspection Fee PERMIT VALIDATION Permit Fee PERMIT NO. DATE APPROVED Cash Deposit -Surety Pond if requi:red 'EXPIRATION DATE DATE ISSUED Receipt No. By Received by Date Ad rn in istrative. Authority Recorded by TELEPHONE: 61 9)564-2246 � i NOTE: With proper validation this form constitutes an CITY OF LA QUINTA. encroachment permit APPLICATION FOR PERMIT PUBLIC WORKS CONSTRUCTION (ENCROACHMENT) I 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: — ^ �6 Minor Improvement Permit Class IV LOCATION OF CONSTRUCTION _ (Street address or Description of Location) PURPOSE OF CONSTRUCTION ��-�� Sketch (attach'construction plans if appropriate) D6SCRIPT10 CONSTRUCTION DIMENSION OF INSTALLATION OR REMOVAL i SIZE OF EXCAVATION, IF NEEDED 4 APPROXIMATE TIME WHEN WORK WILL BEGIN 2 dpl�, APPROXIMATE TIME OF COMPLETION ESTIMATED CONSTRUCTION COST $ !Inelud;ng rerrrovai;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 atrleast twenty-four (24) hours in advance of the time when work will be started. Comply with all applicable City Ordinances, the terms and conditionsof the permit and all applicable rules and regulations of the City of La Quinta andito pay for,any additional. replacement necessary as the result of this work. Signature of ApOflcant or Agent Business Address Name of Contractoned Job Foreman, Business Address I Telephone No. 0 Contractor's- ficense No. City Business$ficense No. Applicant's.onsurance Company Policy Number FEES: Subdivisiom Improvement Permit —Class III Public improvements: 3% of estimated construction costs Private improvements: 3% of estimated construction -costs f O Minor Improvement Permit — Class IV: See attached schedule " Inspection Fee ` $ — Permit Fee Penalty Cash Deposit -Surety Bond if required TOTAL: $ �D- Receipt No. Received by k Date Recorded by PERMIT VA IDATION PERMIT NO. DATE APPROVED . EXPIRATION DATE _q, DATE ISSUED .By TELEPHONE: (611 Administrative Authority