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• With .proper validation • F _
this form constitutes an
encroachment permit
+, CITY OF •LA•QUINTA 3
7 •� ` �
APPLICATION FOR PERMIT ' • �,
•a` . � - ,r.' PUBLIC WORKSCONSTRUCTION (ENCROACHMENT)
For the construction of public or -private curbs,- driveways, pavements, sidewalks,
'parking lots, sewers, water mains x ,
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS'.,! 1'
Subdivision Improvement Permit -:Class I I I - a'
'DATE: �J Minor Improvement Permiss IVI
t Class r
' LOCATION OF CONSTRUCTION
h e
(Street address or Description of Location) _ r - - ' r •• r
f1 • l I ;` r
PU SE OF CO T )Sketch (attach construction plans if appropriate)• r
DEC IPTION 4CON$311UC.TION �•_ _�'
DIMENSION OFf gT CATION R REI-V.��}V•AL '_' rt r `5 ,f 3• r v
baa—'6•. f
h_ t
•SIZE OF EXCAVATION, IFN - •.�t •-+.^� � x�• ,� +
APPROXIMATE TIME WHEN WORK WILL BEGIN " •''. _ i.; ! •r
APPROXIMATE TIME OF COMPLETION, r • j `, t ;
ESTIMATED CONSTRUCTION COST $ •. i .
Y X (Including removal of,all obstruction, materials, and debris, backfilling, com-
paction and plaoing permanent resurfacing and/or replacing improvements)
I� In consideration of the granting of this permit, the, applicant. hereby agrees to: + f•' tom'
r
`. 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 "
t
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'
• 4 4 , Comply with all applicable City Ordinances, the terms and conditions of the e t and all applicable r a• regulations of the City, of.
"La Quinta and to pay for any additional replacement necessary as the resu o his work.
�� {• ignature of or gent
I w. Name of cant (please print) Business Address 1 Telephone No.
r •'Nam o o actor and Job Foreman t. s Business Address Telephone No.
Contra tor' License City�iusinesslicense No. t �,
o
�+
Applicant's Insurance Company r o�. / Policy Number
.rte -
FEES:Subdivision Improvement Permit — Class
"r. Public improvements: 3%,of estimated construction costs
F. i ems.
Private improvements: 3%of estimated' construction costs
` Minor Improvement Permit — Class IV: See attached schedule; -1714 k ,
Inspection Fee $ t PERMIT VALIDATION''
t 4 -Permit Fee `„� �.y �r tPERMIT N 7j
. Penalty , O
~
'Cash Deposit -Surety Bond * ' DATE APPROVED"
+ 'r if requiredEXPIRATION_ DATE-
+.
• .. t TOTAL: ,v$�(ll/ --
DATE ISSUED
.r f Receipt No.
By ti
�• . r Received by ' Date • ";
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