0624'NOTE: ,
With proper validation ,, Q
this form constitutes an
CITY .OF LA QUINTA' . � �
encroachment•permit. , . . . r.:
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION .(ENCROACHMENT)
c�'
- OF 'PH89
For., theconstruction • of,..pu6lic or private.. cu'rbs, driveways; pavements, 'sidewalks, .parking I.ots"-sewer's, water mains I`
and otheri like publicworks improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS,
r ; }t v.
r T 4 k Subdivision Improvement Permit — Class -111
DATE: t Minor I'mprovernent Permit Class IV '
LOCATION OF CONSTRUCTION
(Street address or Cescription of Location)
PURPOSE OF CONSTRUCTION:Sketch •(attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION ,
DIMENSION' OF INSTALLATION OR REMOVAL
SIZE OFEXCAVATION, IF NEEDED
•
..APPROXIMATE. TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION , M
ESTIMATED CONSTRUCTION COST $ `
(Including removal of all obstruction, materials, and debris, backfilling; com
paction and placing permanent resurfacing, and/or replacing improvements)_.
'In conside'ratio'n 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
Ca Quinta and to "pay, for any additional replacement necessary as the result ofIthis work.
Signature of Applicant or Agent
Name of Applicant (please print) BusinessAddress Telephone No.
Name of Contractor and Job Foreman ' Business Address Telephone No.
Contractor's License No.City Business'License No.
Applicant's Insurance Company F ' Policy Number
FEES: Subdivision, Improvement. Permit = Class III � -
Public improvements: 3%.of estimated construction costs
Private improvements:'.3% of estimated construction costs
{N0 0024_
Minor Improvement Permit,— Class IV: See attached 'schedule.
Inspection Fee $• PERMIT VALIDATION .
Permit Fee PERMIT NO.
Penalty DATE APPROVED
Casli Deposit -Surety Bond ;
if required EXPIRATION DATE
TOTAL: $ DATE ISSUED
•� y -
Receipt No. By `
Received,by ' Date Administrative Authority
Recorded•by TELEPHONE: (619) 564-2246 - '
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NOTE: T /
With proper validation, fQ r
this form constitutes an
' CITY 'OF LA QUINTA
encroachment permit . = b
APPLICATION FOR PERMIT --
_" PUBLIC WORKS CONSTRUCTION. (ENCROACHMENT)
0
,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 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 theipermit granted pursuant to this application:
Notify the. Administrative Authority,at least twenty-four`(24) hours•iri 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 of Applicant or Agent .
• Name of Applicant (please print) 'Business Address.. Telephone No. -
Name of•Contractor and Job Foreman Business Address•w Telephone No..
4r,
Contractor's. License, No.. ' City Business License No.
Applicant's Insurance Company r Policy. Number
.FEES: Subdivision Improvement Permit - Class III
Public improvements: 3% of estimated construction costs ' y
Private improvements; 3%of estimated construction costs' '
Minor Improvement Permit.— Class IV: See attached schedule ..i
N2 0,624
Inspection Fee $ ;? PERMIT VALIDATION
Permit Fee , -41
PERMIT NO.
Penalty V
Cash Deposit -Surety BondDATE APPROVED I
if required AEXPIRATION DATE
TOTAL .t $ l DATE'ISSUED i v
Receipt No. ,
By.
Received by Date - • _ , Administrative Authority
`. .Recorded by TELEPHONE: (619) 564-2246
•
I f
1 +
NOTE: '
With proper validation
this form constitutes an • `
encroachment permit.
9
J CITY OF LA QUINTA
APPLICATION FOR PERMIT }
;• PUBLIC -WORKS CONSTRUCTION (ENCROACHMENT)
M
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 APP ROVED,SUBDIVISIONS
J fr J' Y ;. :•'.3' eJ?, e: f . fes.. r"�l . i• + - • '
Subdivision Improvement Permit -Class l l l
DATE: Minor Improvement Permit Class IV .
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
y 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 and placing r
p g ,permanent resurfacing replacing improvements) •
In consideration pf 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 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 Tp 0624
Minor- Improvement Permit — Class'IV: See attached schedule
r•,
Inspection Fee $ - PERMIT VALIDATION
Per Fee 'PERMIT NO..
Penalty,
Cash.. Bond DATE APPROVED
.
if required .. EXPIRATION DATE%
` TOTAL: $
Receipt No. '
Received by Date
Recorded by
DATE ISSUED
j By
Administrative Authority
TELEPHONE: (619) 564-2246
f .r: �� . •� .�� � �� ��..� �� �. � �.� �� �� .� � �� �� �� � �� a �� ..-w_ _-�.
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
and other like public works improvements. in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
S- 3 JG'G Subdivision Improvement Permit —Class III
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION
DESCRIPTION, CONSTRUJ_ 1.CT�I� `'' �
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
Sketch (attach construction.plans if appropriate)
' • l 1
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 of any work undertaken under the permit granted pursuant to this application.
Notify the Administrative Authority at least twenty-four 124) 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 of Appl nt or Agent
Name of Applicant (please pr' t) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's Lit4nse No.
1 %h
City Busine License No.
Applicant's In$urance Company Policy Number
FEES: Subdivision Improvement Permit — Class III
Public improvements: 3% of estimated construction costs
Private improvoments: 3% of estimated Construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee
Permit Fee
Penalty
Cah Deposit=Surety Bond
if required
TOTAL:
Receipt No.
8 J O—
Received by Date
N° o6z�
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED .
EXPIRATION DATE
DATE ISSUED v
By
Recorded by II TELEPHONE: (619)
Administrative Authority