0939 (2)NOTE: 3 ,
With proper-wiidebo6i,,
this form corAtitutesan = CITY OF LA QUINTA :
encroachment`nermit • v
APPLICATION'c,FOR' PERMIT
x PUBLIC�� WORKS.:CONSTRUCTIONAENCROACHMENT)
For the construction' of public or private,.curbs: -driveways, pavements;- sidewalks, parking lots, sewers; wa11
ter tneit�r`>
and'other Iike public works improvements- in connection with M I NOR 1 MPROV EMENTS and APPROVED SUBDIVISIONS"
s -Subdivision improvement Permit - Class lit
DATE: %-2 - o Minor improvement PermitClass•iv
LOCATION OF CONSTRUCTION ' 'l
t 1$ttaet addi'aaa"Of t±alalp�011 Of LOQt1011i:�.' •' -
PURPOSE OF CONSTRUCTION- JbZ�,&= All Trro kc'H Sketch (attach construction pians if appnoprigm)o::
DESCRIPTION OF CONSTRUCTION', I ` K `1nia 1�4
OIMENSION OF INSTALLATION OR REMOVAL Z 42''`X
SIZE OF EXCAVATION, IF NEEDED.
APPROXIMATE TIME WHEN -WORK WILL BEGIN z-2:
q o
APPROXIMATE TIME OF COMPLETION I - 2- `t - iso '
'ESTIMATED CONSTRUCTION COST'S
(Including removal' of all obstruction, materiais, and'debris, bar-kfilling; cpm-
paction and placing permanent resurfacing and/or replacing improvements)
Inconsideration of the granting of this permit, the applicant hereby agrees to:
Indemnity, defend and saw the City, its. authorized agents, officers. represenntives and employees harmtess from and against-anw ew sn'
penalties: liabilities or loss resulting from claims or court action and arising out,of any accident,- loss or damage4a persons or, propmy'
happening or occurring as,a proxirtna, result of anv work, undertaken<undarthe 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 Oidinances; the terms and conditiota of the pecan and All applicable rules and regulations of the CltV of
La Quints and to pay for any,additksnal replecernent necessary as'the result of r,
a
Signal r 6f Applicant or Agent
iVPU� �9c°t�Y % Ni �ioti ,w`/�Od f �aa Z''/DI
Name of Aopucant (please print) Business Address Telephone No.
Name of Contractor an Job Foreman Business Address Telephone No.
Contractor's License No. , - City Business License No.
f��i ��i�i"c .�c� rter .�Qd•� � �P� - '. � �6�r2•b.� ff t�G i - '.
A'ppticant's Insurance Company Policy Number
FEES: Subdivision Imorovement Permit - Class I II' ;
Public improvements: 3% of estimated construction costs
Private improvements: 396 of estimated construction costs *TO Cr
Minor Imorovement Permit - Class.II7V.- See attached schedule j
inspection Fee S 3fJ I PERMIT VALIDATION
Permit Fee
PERMIT NO.
Penalty DATE APPROVED'
Cash Deposit-Surety'Bond
if -required. EXPIRATION DATE' `
TOTAL: $ DATE ISSUED '
Receipt No. • ' I
l By
Received by' Date Administrative Authority
Recorded, by TELEPHONE:,(6191664-2248