2821 (2)+ .;1,[.•+
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c `M NOTE: V.,`'.
With proper validation
^� this form constitutes an �� }• ;
- J ••CITY. OF LA'.QUINTA
encroachment permit
T AOPLICATION,'FOR PERMIT f' :
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
2 Subd'sion Improvement Permit — Class III
` } DATE: - ` ) %.- Minor Improvement Permit Class IV ,A
LOCATION OF CONSTRUCTION- O—ng. r O 55'Cn6W
- - '(Street address Description of Location)
/ `- r •
` " i. .4 r PURPOSE OF CONSTRUCTION /��/ vim` /ch'(attach construction plans if appropriate) +
t ,
• I DESCRIPTION OF CONSTRUCTION ' rA( yMj �J • h�VL�^^1 w• `�j`
r r s C DIMENSION OF INSTALLATION OR REM L f t
01
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BE_ GIN72
APPROXIMATE TIME OF COMPLETION 7 • + ' - �`+'' Y �f
.r
1 ESTIMATED CONSTRUCTION COST $
' .(Including removal of all obstruction, materials, and debris, backfilling, com- , - • ' ,
" r
• paction and placing permanent resurfacing and/or replacing improvements)
a . In consideration of the granting of this permit, the applicant hereby agrees to:
Indemnif defend ,and save the City, its. authorized agents, officers, representatives and employees, harmless from and against an and all A • • ' ' V.� V, 9 P9 Y
penalties, liabilities or loss resulting from claims or court action and arising out of,any accident, oss or damage to persons or property •f ��
;happening or occurring as a k proximate result of any work under the permit granted ur ant to this application. '
't, t Notify, the Administrative Authority at least twenty-four 124) hours in advance of th time a work will be started. 4 -'
Comply with all applicable City Ordinances, the terms and conditions of the and al livable rules and regu ations of,the City of
La Quinta and to pay for any additional replacement necessary as the resul his wor �jl/\^J\
6WIS
Sig f pp�jica o gent
A(_Alt�
n Name of Applicant (please print) , •{ Busin s[ ddress' / ' Teleph ne No.
a o/� ac or and For Buslness.Address , Telephone No..
Contra is Lice o. r. /r ' .. City Bus' e s c cease v
Applicant's Insurance Company ' Policy Number,
`.}. FEES: 'Subdivision Improvement Permit — Class III
V 1.
Public improvements: 3% of estimated construction costs
• Private improvements: 3% of estimated construction costs
• s {' �' ?�31 Minor Improvement Permit — Class IV: See attached schedule 2.7 7 4 ; s
Inspection Fee $ L PERMIT VALIDATION. M
' tonr
N . , Permit Fee 'PERMIT NO. r
Penalty ... `
t iDATEAs e
Cash Deposit -Surety Bond PPROVED .�' +
if required :EXPIRATION DATE
t TOTAL: .$ + -
��bc . DATE ISSUED ..'
Receipt'No.. M '�
,L. 'By ^•
t 'Received by Date Administrative Authority
Recorded by '` r Telephone: (619) 777-7075 f
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