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1098a.a.«�r",« x.. s... +__ t..,•. .z__,..� ( ..r .. _,.+...:..,_.. - ,t: ....., %r :.r„,,,t.,,. ,.. da,.�,.. ..�...-"'..d.,,,A. 'w, .1,21 ..rt. cs ., «.. AOT' F• . With proper validation thisform constitutes an CITY OF. LA QUINTA encroachment permit APPLICATION: FOR PERMIT PUBLIC WORKS-CONSTRUCTION'.(ENCROACHMENT),c� „ 0F T88� For .the construction of public ,or. privates' curbs,. driveways, pavements,' sidewalks, • pa•rking .lots,,. sewers, water *mains and other like public works improvements in connection with MINOR IMPROVEMENTS and APP-ROVED,SUBDIVISIONS . . Subdivision Improvement Permit- Class I I I "DATE: Minor Improvement Permit Class IV :. LOCATION OF CONSTRUCTION. (Street address or Description of Location) "PURPOS OF. fSl . RUCTION Sketch (attach construction plans if appropriate) ' QWA 4 —DESCRIPTION OF -CONST UCTIONOL Lj d DIMENSION OF INSTALLATION OR REMOVAL I ' SIZE OF EXCAVATION,•IF NEEDED �.[ �. [// APPROXIMATE TIME WHEN WORK WILL BEGIN APPROXIMATE TIME OF COMPLETION a ' ::.ESTIMATED CONSTRUCTION'COST $ ` :; •.•(Including removal, of .all obstruction, materials, and debris, backfilling, com- ' t . pactiowand•placing, permanent resurfacing and/or replacing improvements) 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 per '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'reguIations.of thI e City of <La" Quinta_and to pay. for any additional replacement necessary as the result of this work. Signature of Applica Agent �•� IL D Name. ofApplica (please print) Business Address, •Telephone No. Name of Contractor and Job Foreman Business Address Telephone No. ' Contractor's.License]�N�o^.�ys City Business License o. 'Applicarnt's.Insurance Company :-,- Policy'Number ' FEES:.' Subdivision] mprovement.Permit — Class I II 1 Public improvements; 3% of•estimated construction'costs ;Y ` Private improvements: 3% of estimated construction costs.; V Minor, Improvement Permit —'Cl, ass IV: See. attached schedule Inspection Fee $ PERMIT. VALIDATION Permit Fee PERMIT NO.. •Penalty. . . Cash Deposit -Surety Bond DATE'APPROVED 121 if;re.quired EXPIRATION DATE �� l� �i TOTAL. $ • DA f ISSUE Receipt No.. By'. Received by Date Administrative Authority . a Recorded by ` ... TELEPHONE: (619) 564-2246 • 1 K NONE: ,t With proper validation this form constitutes an encroachment permit CITY Of LA QUINTA APPLICATION FOR PERMIT PUBLIC WORKS CONSTRUCTION (ENCROACHMENT) I 4i • 4• 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 _ I Subdivision Improvement Permit — Class III DATE:Minor Improvement Permit Class IV LOCATION OF CONSTRUCTION I (Street address or Description of Location) PURPOSE OF CONSTRUCTION Q1010 Sketch (attach construction plans if appropriate)hJ .. a DESCRIPTION OF CONST UCTION�C co f .• Mme► I •� � DIMENSION OF INSTALLATION OR REMOVALCLUJ 1 i �I AO SIZE OF EXCAVATION, IF NEEDED I i 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 replacingimprovements) + In consideration of the granting of this permit, the applicant hereby agrees to: i 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 e 'La Quinta and to pay for any additional, replacement necessary as the result of this work. Signature of Applican.to{Agent �1 o� .11) ej Name of Applicar/ (please print) Business Address Telephone No. Name of Contractor and Job Foreman Business Address Telephone No. R, 151 Contractor's License No., City Business License o. Applicant's Insurance Company Policy Number FEES: Subdivision Improvement Permit — Class I Public improvements: 3% of•estimated construction costs 1 Q 9'U Private improvements: 3% of estimated construction costs U Minor Improvement Permit — Class IV: See attached schedule . Inspection Fee $ PERMIT JVALIDATION Permit Feel PERMIT NO. . Penalty / n Cash Deposit -Surety Bond DATE APPROVED if,required EXPIRATION DATE TOTAL: $' DATE ,ISSUE c% Receipt No. By Received by Date AIX Administrative Authority Recorded by TELEPHONE: (619) 564-2246' " P M p Y.— Ea — 9 1 MON 1 01 0 M AS w 1O� �� MAY r1` �� r� � �.r Y �� il.s . _ ��f r.�i �! Y.► r. � w� . NOTE: WNhDraw velidie n . this form eonilvan" an CITY OF LA GUINTA #ht<Ca0!lnhfrit ofrmer APPLICATION FOR PERMIT PUBLIC WORKS CONSTRUCTION (ENCROACHMENT) Far the tonsrruMoa of pubtle or privets curbs, driveways, Pavements, Iidwwikt, parking lost, wwers, Yrreargta4tr, and other Ilk# public work% irrioro"rno rm in connection with MINOR IMPROVEMENTS and APPROVED SUSCIVISIDw ! t SubdlYftion Improwmfnt Pennrt .• CWs III DATE. I .y Mina' Imprommiam Permit CIM IV .........� LOCATION OF CONSTRUCTION ISM«% edgrr� dr O.arvoa+r of LtiaveM , PURPOSE OF CON UCTION Sketch letatth ea mnalon piarq;f apprap f DESCRIPTION OF CONSTRU=ON uGiwl Rhe. , m �YAae4j f Qi'& OMMEN$lON OF INSTALLATION OR REMOVAL —Tel ptVe, 5 t/� ah � 0 C5q SIZE OF EXCAVATION, IF NEEDED APPROXIMATE TIME WHEN WORK MULL BEGIN t�'•' Mfr. is APPROXIMATE TIME OF COMPLETION ESTIMATED CONSTRUCTION COST S (Including femoro of all obrtrtrction, hiatenels, and debris, bockfiliing, Dom• pacoon and Placing 0amwrom rnurtusrq and/or e#placing improv#manal In eonadtratlon of 011 prlttng of this permit, the applicant hfretly "TM to: Indmmn1W, drMd #M awe the Clry, hb whomed aura. otlfoNn. NONwr.tv"M Nd #mw0w*"' n#nMaq trvrrh"a+wo nisi arra W WAIlb", Iia ION b 40 NWHOTp horn M**M or wort #"19n and arwd%§ &A of any IMAtant. 1023 cur ownw 10 Mr�One or ""'w"',.. ftev"t nil or 0 w-nq 0 # proxomw tawn of MW wfou vftwu tun unow the on vii 1MR190 purr,ent to the aloOM*^ NOUN tna Apm,nrnrdrrra Au*Awt%v at ha+n e«0„w4wr 441 *Xn in eaveme M IM tvN Vahan Mora anll bg COM01V Mph II r: a aowKad�GtlrORta+r�ore,tMtanm,�ll,. r''�f;IdyapaneRerd%1•aoWbtN�n,trbdhgWrR4rr•ol,tlre�tH'�fN'�,`.'•`''n','". tw for any,`aOdhior:ei'.i wacwrry;ic NrMlwt til 4+23 wo,K. 4, ... S;tmetun t►UCini or Aa t Name of Aawrant tolessa pint} Bwsunfu Address No. Name or Contractor ant Job Foramen Sutrnass Address No. Cohtractor't L'cent# No. City Business License No, Oro Apptwlnt'% Insurance Cwtomy Policy Numoaat FEES: Subdivision lmopwsmem Perms « Choi Ui Public imoraverrwitt: 3% of r omated can.truction com Private .mpro+-wwits: 3% of *=noted eanteruct,on Com N� Minor (nlnrovenhent Permit - Class IV: $cur #rtamed schedule a +ntorretmh Fee S — Permlt Fee • .Penury � Calls 0#Doan-Sursty Bond it rlt0uvrtl TOTAL: t .`.,.� P"10t No. AM—Yed by RQoporetad by PERMIT VALIDATION DATE APPROVED EXPIRATION DATE DATE ISS% 0 8v M Admrnaaatin A owny 'MLEPHONE:101916M."ut . ' . . + q h �•u '+`. --- t ------_ -------•--------------------�?1,¢..♦tr' `•--------- Ik NOTE: With proper validation Co., t this form nstitutes an CITY OF CA QUINTA: ' 1 ,,• encroachment permit -• a.• a. v APPLICATION 'FOR PERMIT + <. • fg WORKS CONSTRUCTION (ENCROACHMENT)., %For the construction 'of public or`priva4'curbs; driveways, pavements, sidewalks, parking lots, sewers, water mains < a and other like public works improvements in connection with. MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS s- a i • �- Subdivision Improvement1ass Permit — ClIII Min =. a DATE: or Improvement Permit Class IV .,. w ~ LOCATION OF CONSTRUCTION • h a' (Street ad&ess or Description of Location) . G • PURPOS • OF C�NSTRUC ION Sketch (atta h construction plans if appropriate) r ' —1 ` DESCRIPTION OF CONSTFIUCTION DIMENSION OF INSTALLATION OR REMOVAL bi , SIZE OF EXCAVATION, IF NEEDED f ad t Lkn LZo r♦ i 'APPROXIMATE,TIME WHEN.WORK WILL,BEGIN r I APPROXIMATE TIME OF COMPLETION ' ( , �,, • ESTIMATED CONSTRUCTION COST, $ - N_ w• - . (Including removal of all obstruction,' materiali, and debris, backfilling, corn- - 'paction and placing permanent resurfacing, and/or 'replacing improvements) ti s In corisideration 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 ti i 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. ' ti yComply with all applicable City Ordinances, the terms end .conditions of,the permit and all applicable rules and regulations of the City of , • ( - LaxQuinta`--and to pay•for any additional replacement necessary as the result o1 *this work. '" • y Y - r t - � , i •� �' ° / . , � � , � JS Signature of Applica Agent Name of Applica (please print)' Business Address—Telephone No. Name offf C�(o�ntractoyr. and Job Foreman ' Business Address r ! 'Telephone No. • r" Contractor's License No, _ City Business License o. Applicant's Insurance Company • Policy Number !• FEES: Subdivision Improvement Permit —' Class III ' + Public improvements: 3% of estimated construction costs 1 ,OU 9, p t. Private improvements: 3% of estimated=nstruction costs Minor Improvement Permit Class IV- See attached schedule i pz ' .�,', Inspect on Fee $• PERMIT VALIDATION < T Permit Fee l� PERMIT NO. Penalty • .• t Cash Deposit -Surety Bond DATE APPROVED t " 4- if requiredYQ /l /1 EXPIRATION_D TE' TOTALS ID`l��)'.. r; • , " $ ., DA- E ISSUE l �r Receipt No. t i Received by Date Administrative Authority � .+ r , Recorded by ' ,^` TELEPHONE: (619) H4-2246 +''c .•;