2121NOTE:
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, sewers, water mains
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
-ry ! Subdivision Improvement Permit — Class I II
DATE: t
L4-9 Ll Aveinor Improvement Permit Class IV
LOCATION OF CONSTRUCTION �"� �� f - Lit rrertc.
(Street address or Description of Location*)
PURPOSE OF CONSTRUCTION
DESCRIPTION OF CONSTRUCTION C -1.4-t- kI/A (7 k Lb
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN LL 11 -9q
Sketch (attach construction plans if appropriate)
PQ 2. �1112 rS t�C.. Cov�-�
APPROXIMATE TIME OF COMPLETION,' H - 14
ESTIMATED CONSTRUCTION COST $ HE G�
(Including removal of all obstruction, materials, and debris, backfilling, com-
paction and placing permanent resurfacing anal/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 additional replacement necessary as the result of this work.
r
wt Signature of Applicant or Agent
Name of Applicant (please print) Business Address Telephone No.
� \a�C�_
Name of Contractor and Job Foreman Business Address Telephone No.
On 11l0- •9,1(a .
Contractor's L cense No. City Business License o:
Applicant's Insdrance Company Policy Number
lbA A ..n
FEES: Subdivision Improvement Permit — Class 111
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction'cosfs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee • $
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by
to -
Date
2121
PERMIT VALIDATION
PERMIT NO. C;?
DATE APPROVED J4 ` 1
EXPIRATION DATE tt !I - -1'-(
DATE ISSUED 44 OI Lr
By
Administrative Authority
Recorded by 11 ' TELEPHONE: (619) 564-2246
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