2811 (2)0
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NOTE: y
With proper validation
this form constitutes an CITY OF LA QUINTA
encroachment permit
APPLICATION FOR PERMIT -906
PUBLIC WORKS CONSTRUCTION. (ENCROACHMENT)
s OF
For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains
4 and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS I
Subdivision Improvement Permit — Class l l l
DATE: Mior Improvement Per it Class IV
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LOCATION OF CONSTRUCTION
(Street address or Description of Location)Gr.
PURP SE F CONS RUCTION Sketch (attach construction plans if appropriate) '
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OESCRI TION F CON TRUCTION wcu&Y
DIMENSION'0F INSTALLATION_ OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
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r APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $
(Including removal of all obstruction, materials, and debris, backfilling, com
paction and placing permanent resurfacing and/or replacing improvements)'
t In consideration of the granting of this permit-, the,applicant. hereby agrees to:
Indemnify,. 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 of court action and arising out of any accident, loss or damage .to persons or property
' happening or occurring as approximate result of any work undertaken under the permit granted pursuant to this application.
iNotify 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 a a ble rules and rigulations of the City of -
La Quints and to pay for any additional replacement necessary as the ult of this work.
Signa ure of A (Dant or en,
xL.,d& 7 &;AW
Name of pplicant (Ple rint) Business Addr!1 / Telephone
,Pas a� lio
Name of Contractor and Job Foreman Business ddress Telephone N0.
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Contractor's License No. City Business License No.
CO
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Class ill
Public improvements: 3% of.estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class FV: See attached. schedule. 2774
Inspection Fee $ PERMIT VALIDATION
t
Permit Fee PERMIT NO.
Penalty
Cash Deposit -Surety Bond DATE APPROVED 16
if required. EXPIRATION DATE D
TOTAL: , $ DATE ISSUED,
Receipt No. `
By
Received by Date .Administrative Authority
Recorded by l ' Telephone: (619) 777-7675
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