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With proper validation
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this form constitutes an
CITY • OF LA QUINTA`, {. •;
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encroachment permit' t..
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APPLICATION FOR ;PERMIT ,
PUBLIC WORKS CONSTRUCTION. (ENCROACHMENT)'' '
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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 SUBDIVISIONSz-
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Subdivision Improvement Permit —� Class III
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'LPqATION
DATE: �� Minor Impr v ment Per it Class. IV
OF CONSTRUCTIONQ.� tY►M ;
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'I 'ISfreet address or escription of Locatio
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PURPOSE OFCO RUC IONy S etch attac nstruct'p�n plans if appropriate) Q
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DJS�M TII 0ONST UCTION
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DI SION OF IN TAL�AT ON ORREMOVAL
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a ! SIZE OF EXCAVATION, IF NEEDED { n • %'
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-APPROXIMATE TIME WHEN WORK WILL BEGIN "•+ • 4 * ,
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' APPROXIMATE TIME OF COMPLETION '} '
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! -ESTIMATED CONSTRUCTION COST $
(Including removal of all obstruction, materia s, and debris, backfilling, com-
paction and placing permanent resurfacing and/or" replacing improvements) 4
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i• In cons ideration,of the granting of this permit, the applicant hereby agrees to:
Indemnify, defend and save the City, its authorized agents, offic rsrepresentatives g•a-nd employees, ees harmless from and against an ,and all r
penalties,liabilities or loss resulting from claims or court action and arising out of'anyaccident, 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. ,
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Notity,the Administrative Authority at least twenty-four 1241 hours in'"advance of the time when work will.be started.',-
Comply.with allapplicableCity Ordinances, the terms'and conditions of the permit and all applicable rules and regulations of the City of -
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Le Ouinta and to pay for any additionalreplacement.net:eE58ry as the re ult of this wprk.. ,
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f s tur of licant on nt
Pg 971 C(�-AppX220 -
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Name of Applicant (please print) Busl ess Address I Telephone No"
Name of ntractor and Job Foreman Business Address + -
Tele hone No.
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Contractor's License No. r t t' City Business License No.
Applicant's Insurance Company - , Policy Number +
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FEES:- Subdivision Improvement Permit= Class I II
"'Public improvements: 3% 6f esti mated'construction costs
Private improvements: 3% of estimated construction costs ,
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Minor Improvement Permit — Class IV: See attached schedule •' - 2 7 7 431
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Inspection Fee $
PERMIT VALIDATION
Permit Fee UD
PERMIT N
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DATE APPROVED
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if4equipedEXPIRATION
DATE
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TOTAL:$
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DATE ISSUED
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Receipt No. �-IUk11(i
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By
Received by ' Date
�`., Administrative Authority, -
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Recorded by
Telephone: (619) 777-7075 `
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