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NOTE: Owl
With proper validation
this form constitutes an
encroachment permit CITY OF -LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION' (ENCROACHMENT)S'
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
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Subdivision .1 mpr`ovement Permit — Class III
DATE:' O r •� inor Improvement Permit Class IV:�
LOCATION OF CONSTRUCTION` '
(Street address or Description of Location) -
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PURPOSE OF CONSTRUCTION I — Sketch (attach construction plans if appropriate)
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DESCRIPTION OF CONSTRUCTION
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DIMYY§Ij Of INSTALLATION OR REMOVALC It �A
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SIZE OF EXCAVATION, IF NEEDED _ -' " "•-`' .� y
�YAPPROXIMATE TIME WHEN WORK W L BEGIN '— — -
1
/f'APPROXIMATE TIME OF,COMPLETION p1wT CAgs fzEe6 (2, Fi��2t.uA20 •c�IND A'Fi-•.
ESTIMATED CONST RUCTION.COST $ mtAST pizov)Pe FLa6,67JAIC, R7 TiN2A41AM,
(Including removal of all obstruction, materials, and debris, backfilling, com- sniTr (zS rze-7ioN$
paction and placing permanent resurfacing and/or, replacing improvements) 7,
In consideration of the granting of this permit, the applicant hereby agrees to: x �s
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 Adi inistrative•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 Agewt
Name of Applicant (pleaseprint) Business Address- Telephone No.
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Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's cense No. City Business License No.
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Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit,- Class,lII ;
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 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
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