1144 (2)NOTE:
With proper validation
this form constitutes an r
encroachment permit CITY OF LA QUINTA
APPLICATION FOR PERMIT '
PUBLIC WORKS CONSTRUCTIUN (ENCROACHMENT)c 's
�OF TI189w
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
Q C� Subdivision Improvement Permit — Class III
DATE: — l _ ` ' Minor Improvement PermitPlassIV
LOCATION OF CONST,RUCTI N
t:u. f
(Street addressOor Description of Location)
_PURPOSE OF CONSTRUCTIONS Sketch (attach -construction plans if.appropriate)
DE CR PTI 0 0 STRUCTIONlll.
_ C
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
AP ROXIMATE IM WHEN WORK WILL BEGIN
hi
APPROXIMATE TIME OF COMPLETION p1lynf1 I
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:
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 additionalreplacement necessary as the result of.this work.
. Q
Signature of ApTIt,' or Ag t•
Name of Applicant (please print) Business Address Telep ' ne No.
Name of Contractor and Job Foreman , Business Address Telephone" No.
Contractor's License No. 'City Business License No..
Applicant's Insurance Company - Policy Number
FEES: Subdivision Improvement Permit —Class III
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs /L
Minor Improvement - 4
Permit — Class IV: See attached schedule
Inspection Fee $ PERMIT VALIDATION
Permit Fee PERMIT NO.
Penalty v
Cash Deposit -Surety Bond DATE APPROVED
if required EXPIRATION DATE e
TOTAL: $ ' DATE ISSUED
Receipt No.
Received by Date Administrative -Authority
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F NOTE:.
• 4 /
With proper validation
this form constitutes an
encroachment permit "' CITY OF LA .'QUINTA
;.�.z I
APPLICATION FOR'_PERMIT
PUBLIC.* WORKS CONSTRUCTION (ENCROACHMENT)c �S
For' the .construction of public or private .curbs;, driveways, .pavements, sidewalks, parking lots, sewers, water mains
4 and other like -public works improvements in connection with MINOR IMPROVEMENTS and APPROVED. SUBDIVISIONS `
,. _Subdivision Improvement Permit— Class III
DATE: Minor Improvement Permit Class IV'
LOCATION 9F C STRUCTION
(Street address or Description of Location)
_ PURPOSE OF CONSTRUCTION lea Sketch (attach• construction plans if appropriate)
DESCRI IQN OFCN TRU TI - _ -
ILI &F 04
DIMENSION OF I TALLATION OR REMOVAL , X
SIZE OF EXCAVATION, IF NEEDED L 1:1 ;
APPROXIMATE TIME WHEN WORK WILL BEGIN` — /0-977,
I•T ^ - T . ,
APPROXIMATE -TIME OF.COMPLETION j'►'1 - ,. -
ESTIMATED CONSTRUCTION COST $ T .
(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: '
Indemnify, defend,and� save the City, its -authorized agents, officers, representatives and employees, harmless from and against any and all
i 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. ,
i Notify the Administrative Authority at least twenty-four,(24) hours in 6ance•of the time when work♦will be started.
Comply with all applicable City -Ord inances, 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
vw, 9,9 9
Name of Applicant (please print) Business Address t •Telephone.No 3
Name of Contractor and Job Foreman Business Address - `�'V Telephone No.
Yr
Contractor's License No. f City Business. License No:
Applicant's Insurance 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 ` ' • ti` .
*'Minor Improvement Permit.— Class IV: See attached schedule
Inspection Fee $ _ PERMIT VALIDATION`
Permit Fee PERMIT N0. 4 a
Penalty
Cash Deposit -Surety Bond
DATE APPROVED
• z `
if required
Yl EXPIRATION DATE
TOTAL:, $ .. DATE ISSUED ' .
Receipt No.-
By
Received by Date Administrative Authority
Recorded by TELEPHONE: (619) 564.2246 ,