1114 (2)NOTE:
With proper validation
this form constitutes an
encroachment permit
CITY OF LA- QUINTA.
APPLICATION FOR PERMIT
.'PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
i
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: Minor.lmprovement Permit Class IV
LOCATION OF CONSTRUCTION J 3 —ja s"' e� L t'
(Street addressor Description of Location)
PURPOSE OF CONSTRUCTION (attach construction plans if appropriate)
DESCRIPTION OF.CONSTRUCTION V • + -
DIMENSION OF INSTALLATION OR R&M)Wkt .7 S
SIZE OF` EXCAVATION,. IF NEEDED A)odO6'
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION �=� `2 4m r
ESTIMATED CONSTRUCTION COST $
(Including removal of all obstruction, materials; and debris, backfilling, com-
paction
om paction and' 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 anyaccident, 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�thif work.
ignature of Appli "nt or Age . t -y
TA00%ris _& 6) Am'. I
Name of Applicant (please print) - Business Address ..Telephone No.
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t
1 0 A J �' � � � i � 6�� � �A -
Name oof+Contractor "and Job ForemaA Business Address Telephone No.
Contractor's icense No. City Business License No.
��.' rI l l
Applicant's Insurance Company Policy Number.
FEES: Subdivision Improvement Permit —Class I II
Public improvements: 3% of estimated construction costs m
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $ PERMIT VALIDATION '
Permit Fee PERMIT NO.
Penalty
Cash Deposit -Surety Bond DATE APPROVED
if requiredx
EXPIRATION DATE %21
TOTAL: $ DATE ISSUED
Receipt No.
By
Received by Date Administrative Authority
Recorded by TELEPHONE:.(619) 5642246