1002' • f
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NOTE
With proper validation
this form constitutes an ; "
encroachment permit CITY OF ' LA" QUINTA
APPLICATION FOR PERMIT' '
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
0F�
For the construction of ,public or. private curbs, . driveways; pavements, sidewalks,, parking lots, sewers, water mains
and other like public vuorks improvements in connection with. MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
Subdivision Improvement Permit —'Class III
:BATE: � C1 Minor ImprovementPermit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of -Location) "
PURPOSE OF CONSTRUCTION.- Sketch (attach construction plans if appropriate)'
-.!,.'DESCRIPTION OF`CONSTRUCTION
tis , DIMENSION OF INSTALLATION OR"REMOVAL a
y 'SIZE OF' EXCAVATION, IF NEEDED ,
+$SASH 9i$TD� L'Ogb-.9i iw..o04
APPROXIMATE- TIME WHEN WORK WILL BEGIN 1
r; APPROXIMATE TIME OF COMPLETION '} +
ESTIMATED. CONSTRUCTION COST$-,
,(Including removal 'of.all obstruction, materials; and debris; backfilling; com ••; r
paction .and- placing permanent resurfacing and/or replacing improvements) x `
a In consid'eration:.of the granting of this permif,'the'applicant hereby agrees to:
tl i
'Indemnify, defend and save the, City, -its authorized agents, officers, representatives and employees, harmless from and against any and all
penalties,' liabilities'or l'o'ss ;resulting from.•claims or court action and arising out of any accident, lossordamage to persons or property
happening or occurringas a roximate:result of an work undertaken under the ermit ranted ursuant to this a lication ° +: ='
Pp g P Y P 9 P pP
tl Notify the'AdministratiJe Authority'at Ieast'twenty-four (24) hours in advance of the time when work will be started.,
" Comply .with all',applicable City'6rdinances, 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. <<
t `• Signature of'Applicant or Agent;
Name of Applicant (please print),' � Business Address elep_hone No. t
".Name of,Contrictor and Job Foreman Business Address . Y>> Telephone No.
Contractor's'Lic' a No. City Business i ense No.
'Applicant's Ins r nce Company Policy Number
FEES:- Subdivision Improvement Permit — Class I I I
y •,- Public improvements: 3% of estimated constructi,on,costs
Private improvements: 3% of esti mated' construction costs
Minor Improvement Permit — Class IV: See attached schedule j
Inspection. Fee $ PERMIT VALIDATION
Permit Fee 9'O &V
PERMIT NO.
Penalty' i 6
Cash Deposit Surety Bond DATE APPROVED, a- ��
i.f,required EXPIRATION DATE'
.-e'� d�•'�-d =� f
TOTAL:' $ ''hT�- _ a ..v 9
DATE`iSSUE
Receipt No.
By
`Received by Date Administrative Authority
i . Recorded by, TELEPHONE: (619) 564-2246
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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 other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
Subdivision Improvement Permit — Class III
DATE: 1414,1 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION w
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION
DESCRIPTION OF CONSTRUCTION
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)
Sketch (attach construction plans if appropriate)
-Q„ft.0..�Q,r Iii.-�'•3> •
In consideration of the granting of this permit, the applicant hereby agrees to:
i(�5"'&A iA
9$ OT''. Oi -9100.064
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 propeety
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 (please print)
Signature of Applicant or Agent
Business Address
ephone No.
Name of Contractor and Job Foreman Business Address / Telephone No.
Contractor's Licd
,9Le No.w City Business Ddense No.
Applicant's Ins'.once 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 IV: See attached schedule
Inspection Fee $
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by Date ."t
1002
PERMIT VALIDATION
PERMIT NO. /&0'L
DATE APPROVED -a- 16 /f/
EXPIRATION DATE /0 j
DATE ISSUED
By
A-. Administrative Authority
I Recorded by 11 TELEPHONE: (619) 564-2246