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NOTE:
With proper validation
this form constitutes an
encroachment permit
CITY OF LA QUINTA
APPLICATION FOR PERMIT
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
DATE: 10117L25
Subdivision Improvement Permit — Class II I
Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION i � ri r� z!r,CC 205 1 n 'iot �5 c�<1 t cz C1�3
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION
O$k'GC�p 7ty'���i;;i���� t✓C;v�,��U� �.s��'� iQf;"u'C i;�;L;S�GII• c�.f'� :i 7i�!���� �.,'���T`il'��iJn�l.
DIMENSION OF INSTALLATION OR REMOVAL `LL L07
SIZE OF EXCAVATION, IF NEEDED �4— ZL a 21"
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $R
(Including removal of all obstruction, materials, and debris, backfilling, com-
paction and placing permanent resurfacing and/or replacing improvements)
I,n 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 or court action and arising out of any accident, 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.
Notify 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 perrm and all applicable -rules and regulations of the City of
La Quinta and to pay for any additional replacement necessary as the result of/ this ,work.
Signature of Applicant or Agent
Name of Appli �n�t (pleasritB � pr� sinUess AddreT�gep.one No.��%-��291
Name of Contractor and Job Foreman Business Address Telephone No.
.TCV,0���i �ac� - ca; el✓ > c�ta ,o a .� u i5s
Contractor's License No. City Business License No.
OM7714:76
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit —Class III
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee
160.
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
Received by Date
PERMIT VALIDATION .
PERMIT NO.
DATE APPROVED 10/12/q(=
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
Recorded by
Telephone: (619) 777-7075