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NOTE:
With'proper validation
this form constitutes an CITY OF ' LA QUINTA•
encroachment permit '
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENTY . ,
SOF
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: 3� Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION %15 715 4 76-IZ6 -TAMPIC 0
(Street address or Description of Location)
C,Dtj,b tAC'i" 1U ]r
PURPOSE OF CO ST UCTION Sketch (attach construction plans if appropriate)
�P�RoAC. MVizGUAl - APP2V&H- SRALL
DESCRIPTION OF CONSTRUCTION
131E • CD ti.& k A LT ED P F: K
DIMENSION OF INSTALLATION OR REMOVAL 7 • UQ . CATTACHEi?) f
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN 3 -11 Al
•� 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)
In consideration of the.granting of this permit, the applicant hereby,agrees to: J
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'actiori and arising out of any.accident,,los's 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.
r Notify the Administrative Authority at least twenty-four (24) hours in^advance of Ithe 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 i ork. '
9ignfiu,re..o,&Apjl ci ant or Agent
. ' YEPkIAN) Atib KLINE -745116 V�_LIS. 1A 'J"'iD -Z'7-1 4151121
Name of Applicant (please print) Business Address Telephone No.
M010 Va 1 LDC P.
` Name of ContractorandJob Foreman Business Address " Telephone No.
Contractor's License No. •City Business License NO:. ,
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Class 111
Public improvements: 3% of estimated construction costs02 - • , _ _ n c
J. Private improvements: 3% of estimated construction costs. •' 1 V
e Minor Improvement. Permit — Class IV: See attached schedule
Inspection Fee $ 2 0' 00 PERMIT VALIDATION.
Permit Fee 10.00 PERMIT NO. -10 2 to
•
Penalty
Cash Deposit -Surety Bond DATE APPROVED
if,required EXPIRATION,DATE 3r)
TOTAL: $ 30 ' 05 DATE ISSUED 3 + j' — q 1
Receipt No. By
Received by Date A&ministrative Authority
Recorded by TELEPHONE: (619) 564-2246