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0623'NOTE: i / With proper -validation Q this formconstitutesan 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: 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 EMOVAL 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 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 br,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.. E Notify the Administrative Authority at least twenty-four (24) hours in advance of the time when work will be started. Y .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. W Signature of Applicant or, Agent ,Name. of Applicant (please print) Business Address' 'Telephone No. Name of Contractor and'Job Foreman Business Address Telephone No.: . r , Contractor's License No. City Business License No. t Applicant's Insurance Company Policy Number lci•>4 FEES: Subdivision Improvement Permit — Class III Public improvements: 3% of estimated construction costs Private improvements: 3% of estimated construction costs N2 0623 Minor Improvement Permit — Class IV:'See attached schedule Inspection Fee $ PERMIT VALIDATION Permit Fee PERMIT NO. Penalty Cash Deposit -Su rety.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 this form constitutes an encroachment permit CITY OF LA QUINTA 83 - - ` - •- APPLICATION FOR PERMIT � PUBLIC WORKS CONSTRUCTION (ENCROACHMENT),c S 0 TR89� 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 II 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 `r 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 om 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 Quinta andlto 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 III Public improvements': 3% of estimated construction costs , Private improvements: 3% of estimated 'construction costs A� - Minor Improvement Permit — Class IV: See attached schedule ,, N2 0623 " Inspection -Fed ' $ PERMIT VALIDATION Permit Fee PERMIT NO. ' Penalty -Cash Deposit-Surety,Bond DATE APPROVED if required _ EXPIRATION -DATE TOTAL: $ r DATE ISSUED Receipt No.. , By— Received y Received by Date Administrative Authority Recorded by TELEPHONE: (619) 564-2246 ., n.,c +D11-.:{w�7 --T .'.. _ '�f .W -_ . —. _. �- ._.fir __ _ .s Lv��0_ _-, _ - .._ _' -._• .• - — _ _. .. . NOTE: With proper.,validation a Q y this form constitutes an �4 CITY, OF LA QUINTA encroachment permit ' . APPLICATION FOR PERMIT: - ' PUBLIC WORKS CONSTRUCTION (ENCROACHMENT) OF, • '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* • v Subdivision Improvement Permit — Class II l 'DATE: 'Minor Improvement.Permit Class IV LOCATION OF CONSTRUCTION i (Steeet-address or Description of Location)" r PURPOSE OF CONSTRUCTION Sketch (attach construction plan's if appropriate). DESCRIPTION OF CONSTRUCTION ' DIMENS[ON .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.replacing•improvements) In consideration of the granting• of this permit, the applicant hereby, agrees to: Indemnify" defend and save the.City, its authorized agents, offices, 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 permitgranted 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 applicableCity, 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: 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 .. . • *+.ter r;./.w. � .- .. FEES::',Subdivision'lmprovement'Perrriit —Class I.II` �. Public improvements: 3% of.estimated construction costs ` a Privte improvements: 3% of estimated construction costs' , . p , N Minor .Improvement Permit — Class IV: See `attached'schedule , • . r 4 Inspection Fee . $ PERMIT, VALIDATION Permit Fee PERMIT NO. Penalty DATE APPROVED Cash Deposit -Surety Bond if requireds 'EXPIRATION DATE .TOTAL. • $ DATE ISSUED Receipt c t N o. By Received by Date Administrative Authority, Recorded by TELEPHONE: (619) 564,2246•. tl�i�r���"r�f�rix':ir"+"1�:fi✓+"�i� , 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 DATE: Subdivision Improvement Permit —Class Ill Minor Improvement Permit Class IV LOCATION OF CONSTRUCTION (Street address or Description of Location) PURPOSE OF CONSTRUCTION ��'"rASketch (attach construction plans if appropriate) DIMENSION OF INSTALLATION OR REMOVAL HP 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- _7 90 , 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 Quinta and to pay for any additional replacement necessary as the result of this work.. Signature eApplicant or gent WA Name of Applicot (please print) 'o (-16 -,—' / 71 Business Address Ca_ 5�1_ao Telephone No. Name of Contractor and Job Foreman Business Address Telephone No. Contractor's Vicense No. City Busines License No. Applicent'l(nsurance Company Policy Number FEES: 'Subdivision Improvement Permit - Class II I Public improvements: 3% of estimated construction costs 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 N° 063 PERMIT VALIDATION PERMIT NO. DATE APPROVED . EXPIRATION DATE DATE ISSUED By TELEPHONE: (619) inistrative Authority