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NOTE, �
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With proper validations f
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this form constitutes an=
CITY OF • LA' QUINTA '-.
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encroachment permit _ m
APPLICATION FOR PERMIT. ,: ; '
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PUBLIC''WORKS' CONSTRUCTION (ENCROACHMENT) •,
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For the construction of publicor private curbs, driveways, pavements, sidewalks, lcts,•se'wers; water mains
parking a ,•~
and other like public works improvements in connection with MINOR_ IMPROVEMENTS and APPROVED SUBDIVISIONS-"
Subdivision Improvement Permit —Class III'
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DATE: f '• r Minor Improvement mit Class IV
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"LOC6ZPNOF CONSTRUCTION
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t • ' (Street ad ss r Description of Locat/io/p'j/'.�_
a- PURPOSE OFCONSTRUCTION Sketch. (attach construction plans if appropriate)
DESC 1 TION OF QONSTRU` N
DIMENSION OF INSTALLATION OR REMOVALjr
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.SIZE OF EXCAVATION, IF NEEDED 4. 7 z•. " 1~ `'
APPROXIMATE TIME WHEN WORK WILL BEGIN
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( APPROXIMATE TIME OF COMPLETION ti • f +' , + '
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ESTIMATED CONSTRUCTION COST $ o f • '
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(Including removal of all obstruction, materials, and debris, backfilling, com- f-. ", t r• >
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paction and placing permanent resurfacing and/or replacing,improvements)� •.
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In consideration of the granting of this permit, the applicant hereby agrees to:
defend and save the City, -its authorized agents, officers, representatives and employees harmless from and against any and all
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penalties, liabilities or loss resulting from claims or court action and arising out of any accident, -loss or'damage to persons o; property
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' happening or occurring as a proximate result of'any work 'undertaken under the permit granted pursuant to this application. .�
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-Notify the Administrative Authority at leasttwenty-four (24) hours in advance oft time wh w k�will be started.' - •. S,
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Comply with all applicable City Ordinances, the terms and conditions of ,the and all a i le rules and regular' sof the City ofa-
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La Quinta and to pay for any additional replacement necessary as the resu o his work.
Signatgen
Name of Applicant (please print) !- Busin s A ress ' - Telephone NO.''X�i�+ '
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Name o Cgtr d e Foreman Business Address. « Telephone No..
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Co /r ry
r ctor' icense A -a" 1 Cit i s Licen No:'
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Applicant's Insurance Company = PolicyNumber•
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FEES: Subdivision ImprovementPermit —Class III . f y ~•'- _ }
Public improvements: 3% of estimated construction costs r -
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Private improvements: 3% of estimated construction costs - -_ ;.t, • • - "
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Minor Improvement Permit' Class IV: See attached schedule 2 7,74
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Inspection Fee - , l$
PERM_1� __VV/ALLI/DATION
Permit Fee
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PERMIT N0. _~ Yi' / CJSCD
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Penalty
Cash Deposit -Surety Bond
DATE APPROVED f
if required •s +
EXPIRATION DATE "5 ,r
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TOTAL: $
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DATE ISSUED
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Receipt No:
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By
Received by Date
Administrative Authority
Recorded by
.Telephone: (619) 777-7075
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