2782 (2);• , NOTE:
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
9 I3/
DATE: '
LOCATI OF CONSTRUCTION
Subdivision Improvement Permit - Class III
Minor Impfovement Permit Class IV
1 �
(Street address or Description of Location)
PURPO OF CONSTRUCTION GhI `e exce5c; Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION . `
SSE e� co k+1W C,
DIMENSION OF INSTALLATION OR REMOVAL �j' AV S V C-6
p CP. G�
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $
(Including removal of all obstruction, materials, and debris, backfilling, corn-
pacdon and placing, permanent resurfacing and/or replacing improvements)
In consideration of the granting of this permit, the applicant hereby agrees to:
Indemnity, defend and save the City, its authorized agents, officers, representatives and employees, harmless from and against env and ati
penalties, liabilities or loss resulting from claims or court action and arising out of any accident, lou 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 Quint@ and to pay for any additional replacement necessary as the result of this work. '
Name of Applicant
Name of
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se print)
L6 (2-6VN6_1
Contractor's License No.
b Foreman
C(0" 3�r
� Signature of Applicant or Agfrlt pkYNt 0�
� 1v� V1. V1 L-f�tes i S` ) . �3 � ��'• �v.11 arc>,a-�►�� �
Business Address
i;
Business Address
Telephone No fly;
Telephone No.�._�
City Business License_No.
ir-) ,jj, Y -0:v-, 1 a�'��(
r
Applicant's Insurance Company GEN. LIABILITY Policy Number
FEES: Subdivision Improvement Permit -Class III
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit-yCClass IV: See attached schedule
Inspection Fee $ aV
pp 0 PERMIT VALIDATION
Permit Fee Y II Z
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by
Date
PERMIT NO.
DATE.APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
Recorded by ll TELEPHONE: (619) 777-7075