1003;NOTE: F
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,' sew water mains .
and :other like pubiic'works improvements in- connection with M,I.NOR IMPROVEMENTS.and.APPROVED SUBDIVISIONS
- Subdivision Improvement Permit.— Class 1.11,
DATE: 6 9�' Minor Improvement Permit Class•IV'
LOCATION OF CONSTRUCTION .
'(Street address or Description, of Location(
"PU.RPOSE OF CONSTRUCTION Sketch (attach construction -plans if appropriate)
DESCRIPTION F'CONSTRUCTIONrK"'-'�`-�'�-bCJ� _
01
z `�-� Gv�
DIMENSION OF INSTALLATION OR REMOVALt1o,
SIZE OF EXCAVATION, IF NEEDED 4 "
APPROXIMATE TIME WHEN WORK WILL BEGIN
„APPROXIMATE TIME OF COMPLETION
'ESTIMATED CONSTRUCTION, COST $
(Including removal .of all obstruction, materials, and debris, backfilling, com- (�'l;s C�
' paction and placing ,permanent resurfacing and/or replacing,lmprovements) '
`� 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,Adriministrative Authority;at'least twenty-four (24) hours in advance of the -time when work will be started .
Comply withralI applicable,City Ordinances, the terms and conditions of the permit and all applicable rules and -regulations of the City of -
La Quints and to for any additional replacement necessary as the result of -is-work:
' z Signature of Applicant or Aged ;
- Name of Applicant(please print) Business Address. Telephone. No. .
Name of Contractor and Job Foreman Business Address Telephone -No.
�: •� =:.Gem- �..�. _ ' � '
Contractor's License No ; ' k. City:Business acense No.
Applicant's Insura c Company; _..Policy,Number .:
FEES: Subdivision Improvement Permit —Class III' '
Public improvements: 3% of estimated, construction costs r,�__ • _ r 0,03 ` Private improvements: 3% of•estimated construction"costs U O `•'
Minor Improvement Permit— Class`IV: See attached schedule.
Inspection Fee` - . $ PERMIT VALIDATION
Permit Feer PERMIT NO.''{�
Penalty •.,. ,
' DATE APPROVE �-F c -• S
Cash Deposit -Surety Bond T 1'
if;.required EXPIRATION DATE.'
4
TOTAL: $
)'. DATE ISSUED - •
Receipt No: ' r ;
By
Received by ^ Date Administrative Authority
'Recorded by - TELEPHONE: (619):564-2246 .
tr
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NOTE:
With proper validation
this form constitutes an CITY OF LA QUINTA
encroachment permit
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
&Y4w Sze.,. !.o a-60, -roc.,
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
DATE: /6 /q
LOCATION OF CONSTRUCTION rx'«
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION
j
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)
Subdivision Improvement Permit— Class Ill
Minor Improvement Permit Class IV
Sketch (attach construction plans if appropriate)
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 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 Age
Name of Applicant (please print)
Business Address
Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's LicensAo. City Business icense No.
U� r
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit —Class Ill
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
Recorded by
1003
PERMIT VALIDATION
PERMIT NO.
DATE APPROVEDA,
EXPIRATION DATE
DATE ISSUED, --
By xS
TELEPHONE: (619) 564-2246
�
.4
Administrative Authority
• , �„ w -- .. dry' i . ? •
NOTE:.. -
With proper validation (SIM.
this form constitutes an CITY OF L:A 'O,UINTA
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
Subdivision improvement Permit - Class ill
DATE: t Minor Improvement Permit Class IV"
LOCATION OF CONSTRUCTION `
(Street address or Description of Location) A . • `` �, , .
PURPOSE OF CONSTRUCTION Sketch,(attach construction plans if appropriate)
DESCRIPTION OF CONSTR CTIO
0
�-�
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, back/ llin4,'com•
paction and placing permanent resurfacing and/or replacing improvements)
In consideration of the granting of this permit, the applicant hereby agrees to: 1
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 person; or property
happening or occurring as a proximate result of any work undertaken under the permit gransed pursuant to this application.
Notify the Administrative Authority at least twenty-four (241 hours in, advance of the time,vvhen work will be started.
r ,
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules and regulations of the City of
La Quints and to pay for ani additional replacement necesserr as the result of this work.
Signature of Applicant or Agent
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and .lob Foreman Business Address F Telephone No.
Contractor's License No. • City Business License No. '
Applicant's Insurance Company Policy Number
FEES: -Subdivision Improvement Permit —Class Ill
Public improvements: 31Y* of estimated construction costs . t
Private improvements: 3% of estimated, construction costs
Minor Improvement Permit — Class IV: See attached schedule N0
Inspection Fee S I PERMIT VALIDATION
Permit Fee PERMIT NO.
Penalty DATE APPROVED
Cash Deposit -Surety Bond „
if required EXPIRATION DATE
TOTAL: $ DATE ISSUED
Receipt No. By
Received by Date Administrative Authority
Recorded by TELEPHONE: (619) 664.2246