0633 (2)NOTE:
With proper validation
thi's 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 III
DATE: 'nor Improvers it
Class IV
LOCATlOt4/()FCONSTRUCTION.:Zq—,!�2-7,3- E46PZ4�_
(Street address or Descrifition of Location) 11
PURPOSE OF CONSTRUCTION
DESCRIPTION'OF CO„R�CT
_--7A�I1
DIMENSION OF INSTALLATION -OR -REMOVAL
SIZE OF EXCAVATION; IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
Sketch (attach construction plans if appropriate)
APPROXIMATE TIME OF,COMPLETION
ESTIMATED CONSTRUCTION COST $
(Including removal of all ob:,truciion, 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 rmi d II applicable rules regulations of the ity of
La Quinta and to `pay for any additional replacement necessary as t s 9
46 1LijAj CDA)-”fZO-C, /
Signature of Applicant or
Name of Applicant (/please print) �r I / . Bu�ssine`ssAddress q Telephone No.
SLA VC,jo-i i�uNhf,( 6- az ,s� Zove-"c/6�� t� 4AW56-/t7�7a�• i��✓/J����i�Iluy, �'e_� � agZg6; 9 �
Name of Contractor and Job Foreman Business Address Telephone No.
k 3-/'�!5 r G --r �1
Contractor's ycense No. City Business License No.
LAA) 9 —2 - D
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 y N�
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by
Recorded by
Date
PERMIT VALIDATION
PERMIT NO. T' -
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
TELEPHONE: (619) 564-2246
0