0625NOTE: t
With proper validation L
'this`form cons'.titutes an 'CITY OF L•A' QUINTA
encroachment permit
APPLICATION .41 -OR 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•I'mprovement Permit — Class] I I
DATE: Minor.lmprovement Permit Class,IV.
LOCATION OF CONSTRUCTION_
(Street'address or Description of Location) G
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION-
DIMENSION
ONSTRUCTION DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IFAEEDED .
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 placingpermanent 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'andfagainst 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.
a 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 [it
Public, improvements: 3% of estimated construction costs
Private improvements: 3% of estimated.construction costs p ti
- -0025
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 by TELEPHONE: (619) 564-2246
i-
NOTE: y
+With proper-validation 2
this form constitutes an
encroachment permit, CITY �OF LA QUINTA
APPLICATION FOR PERMIT
' PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
C� OF TR$�ws
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 a
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 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 r
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 advarice.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 Ouinta 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. r City Business License No.
Applicarit'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 I N2 . ® 6 2
Inspection Fee $ PERMIT VALIDATION
a
Permit Fee PERMIT NO.
Penalty r• •_ -
Cash Deposit-Surety Bond' DATE APPROVED '
if required EXPIRATION DATE
TOTAL: $ DATE ISSUED
Y
i.
Receipt No: I
L By
Received by Date i Y Administrative Authority
Recorded by TELEPHONE::(619).564-2246
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 otherlike 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
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION,, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
I I . .-N r
ESTIMATED CONSTRUCTION COST $
'(Including removal of all obstruction, materials, and debris, backfilling, ciom
paction and placing
permanent resurfacing and/or replacing improvements)
In consideration of'the,giranting of this permit, the applicant hereby agrees to:
)ndemnify'r defend and save the City, its authorized agents, officers, representatives and employees;harmless' f rom -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.
Corriply 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 (PI ease 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 111
.Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
62rr
s ay
Minor Improvement Permit — Class IV: See attached 'schedule 0
Inspection Fee
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL'. $
Receipt.No.
Received by Date
Recorded by
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
TELEPHONE: (619) 564-2246
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 III
DATE: ' ` G Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
Sketch (attach construction plans if appropriate)
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $�
e(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 (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.
Name of Applicant Ofease print)
Signature of
Busindrss Address
cant or
Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No..
Contractor's Licensee No.
City BusintOLicense No.
Gy✓�L�r/GC .
Applicant's Irjgrance Company Policy Number
FEES: Subdivision Improvement Permit — Class I I I
Public improvements: 3% of estimated construction costs
Private improvements- 3% of estimated construction costs
Minor improvement Permit -- Class IVt See attached schedule
Inspection Fee
Permit Fee
P®n®It;y
Cash Deposit -Surety Bond
if required
TOTAL: L:
Receipt No.
Received by Date
Recorded by
N° 6(07,,'
PERMIT VALIDATION
PERMIT _.-Ill
DATE APPROVED .
EXPIRATION DATE
DATE ISSUED
BV
TELEPHONE: (619
inistrative Authority