0736 (2)$3440-813
NOTE:
With proper validation '
tltts 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
JULY 6' 1990 Subdivision Improvement Permit — Class III
DATE: Mina Improvement Permit Class IV'
LOCATION OF CONSTRUCTION Jefferson St.
ttFaeet address or Description of Location)
PURPOSE OF CONSTRUCTION To install new gas main in TR: a 4ttach construction plans if appropriate)
DESC IPTLpN FF CONSTRUCTION 10 install y' of 41- •. I ast i
0 ome Ic . t., eQinnina 9' E7WPL of Jetterson St.. I:
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN - -
cImedium pressure gas main 30' N/centerline
roceeding west.
APPROXIMATE TIME OF COMPLETION -
ESTIMATED CONSTRUCTION COST S
(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 saw 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 wanted pursuant to this application.
Notify the Administrative Authority at least twenty-four 124) hours in advance of the time when work will be started.
Conyky wM all applicable City Ordinances, the terms and conditions of the permit and Nl applicable rules and regulations of the City of
ti di iitw and to pal► for any addkis" npaawrrnt rtaoasnry as dw work.
J.M , QiS?RS�1Q SUPERVISOR
... of /lppttartt or Agent
SOUTHERN CAL FORM?, :AS p_o_ Anx !nni' Qrn+=-Q res ::g7,k,7j '. (714) 3357742
°`Nesrte of Applicant (PMase print) . Btwinamas Address . Telephone No. -
Nnrte of Contractor and .mob Foremen Waitress. Address Telephone No.
Contractor's License No. City Business Liam No. .
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Claw III
Public improvements: 3% of estimated construction costs ,
Private improvements: 3% of estimated construction costs
Mina Improvement Permit - Claes IV: See attached schedule
Inspection Fee $
Permit Fee
Penalty
Cast Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by Date
Recorded by ---T---
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
TELEPHONE: (619) 564-2246