2774 (2)Is
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NOTE:
_ Withproper validation
this form constitutes an _ y CITY OF L_ A QUINTA . Xf t '
f encroachment permit, r•
f . 'APPLICATION FOR',PERMIT ;t • - y
y PUBLIO WORKS CONSTRUCTION• (ENCROACHMENT) -_y •a'C ^ �54�
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
• t ,� ' ,' ; ^ IhI4, Subdivision Improvement Permit —Class IIIDATE:Min r I ': o (ent Permit Class IV n
+ LOCAT�'y///�//�y/�//y�F CONSTRUCT
ION ! T
r
(Street address or Description of Location) F ' r "• , � ' ', '• . �; - r
PURPOSE OF NST UCTION e� Sketch (attach construction plans if appropriate) �� 3 "•
" DES IP 19 OF CONSTRUCTION
1 - 'DIMENSION OF INSTALLATION OR REMOVAL -
' , �, Mme, "x•. f , t- ,
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
I,.
a I APPROXIMATE TIME OF COMPLETION
r i ESTIMATED CONSTRUCTION COST $
�-• (Including removal of all obstruction, materials,'and debris, backfilling, com- ; u'
' t paction and'placing permanent resurfacing and/or replacing improvements)
+ �� _ _{ i •' In consideration of the granting of this, permit, 'the.applicant hereby agrees to:
�. '.. •+01. - p - +•' 'y' ; -. '
I ndemn ify,: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... 3 1 &
. " Notify.the Administrative Authority at least twenty-four (24) hours in advance of the time when work will be started.• .
'r �'.:, •_ _ Comply' with all applicable -City Ordinances, the-terms and conditions of the perm' _and al a ble rules and regulations of the City of. _
LaQuinta and to pay for,any•ailditional replacement necessary as the result is wor
Y Sig re f p1i t r Agent /_,
.. Name of.Applicant (please print) � :Business Address Telephone No.
A5 0,60we
t I Name of Contractor an Job Foreman Business Address Telephone No. { ,'
r-
- Contractor's Li se.No. ..-./ ..` r.Ci y usine s Livens No.
Applicant's Insurance Company Policy Number, r '
A
? FEES: Subdivision Improvement Permit — Class III F '
*' Public improvements: 3% of estimated construction costs
t Private improvements: 3% of estimated construction costs t'
Minor Improvement Permit — Class IV: See attached schedule 2 774 , r . J' J:
t Inspection Fee $ ' :; �. + PERMIT .VALIDATION
Permit Fee t - • Ts PERMIT NO. ,
• { •. Penalty''
Cash Deposit-Surety Bond . DATE'APPROVED O ( O
s. ,.
<
if, required :EXPIRATION DATE
NOTAL:. DATE ISSUED' •~
• • ��., Receipt No. r. .
t~� i . By Y
Received byDate' "' - , r : Administrative'Authority
Recorded by Telephone: (619) 777-7075 + �'