2826 (2)--------------- --- ----
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r With proper validation
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this form constit iutes an
', CITY OF • LA' QUINTA `
'ye s .hinent
permit r-
'APPLICATION FOR" PERMIT'' }
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- ,-,�;`_•• . ' '.�"• PUBLIC WORKS CONSTRUCTION (ENCROACHMENT). c�M a
For the' constructioncof public or private curbs, driveways„pavements, sidewalks, parking lots, sewers, -water mains°
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and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
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vi Sub_dision Improvement Permit -Class III
DATE: I may' „Minor Improvement Permit Class IV
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'- LOCATION OF CONSTRTU CTInON�(y�
1try` CD4--25
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'I '(Street address or Description of Location)
' PURPOSE OF CONfTRldCTION SketcFi (attach construction plans if appropriate) `
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CTI DEC IPTION OF CONST N .
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UIMEN ION OF INSTALLATION OR REMOVAL t
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SIZE OF EXCAVATION, IF NEEDEDJfr
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APPROXIMATE TIME WHEN WORK WILL BEGIN `W
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APPROXIMATE TIME OF, COMPLETION
ESTIMATED CONSTRUCTION COST $ ZED F twxy'• i " • ;
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(Including removal of all obstruction, materials,'and debris, backfilling, com--
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C paction and placing permanent resurfacing and/or -replacing improvements)' `
In consideration of the granting of .this permit, the applicant hereby agrees to: '` �,�,•' i` '.
Indemnify,sdefend 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 resultin from claims or court action and arising out of an accident, loss or damage to P 9 9 Y g persons or property
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happening or occurring as a proximate result of any work undertaken under the permitgrantedpursuant to this application. '
Notify the Administrative Authority at least twenty-four (24) hours in advance f//hhe-time when work will be'started.
;'-Comply with all applicable City Ordinances, the terms and conditions of the p it and all appl• ble les and regulations of the City of
La Quints and to pay for any additional replacement necessary as the result ark: • ,, •* -
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Applicant or A nt'"
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NarrOf Applicant leaseprint) Business Address~ ,' ;Telephone No. c _
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Name of Contractor and Job Foreman Business Address , • . Telephone No.
Contra r_'s�Li%cense No. City Business License No..
,Policy
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Applicant's Insurance Company r Number, rt
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-FEES: Subdivision Improvement Permit = Class III r •
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Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
w. Minor. Improvement Permit —Class IV: See attached schedule �2 7 7 4
'Inspection' Fee $
^' ', - PERMIT VALIDATION
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Permit Fee t j
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PERMIT NO.`
Penalty
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Cash Deposit -Surety Bond • e-
DATE APPROVED
'if required •
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EXPIRATION DATE
TOTAL:
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DATE ISSUED
Receipt No. -
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By
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Received by Date
Administrative Authority
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Recorded by
• Telephone: (619) 777-7075 ' "