2842 (2)'. - - ,1.. V., •
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NOTE:
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With proper validation
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this form constitutes an "CITY, OF LA QUINTA I
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encroachment permit
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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'iri connection with MINOR IMPROVEMENTS arid APPROVED SUBDIVISIONS '
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O 1 3Q I Subdivision Improvement Permit — Class I I I '
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DATE: - r Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION j /v L l%.� /%IA- -4''.- �LL., %.�i ✓Y1 a my LA
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'.(Street address or Description of Location) .. • -•.
PUR OSE OF CONSTRUCTION I` ���` �1 �~a c , Sketch (attach construction plaAs'if appropriate) '
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D N OF CONS UCTION
DIMENSION OF INSTALLATION OR REMOVAL ' { + • +�` '
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r SIZE OF EXCAVATION, IF NEEDED n •.
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APPROXIMATE TIME WHEN WORK WILL BEGIN ��y 1nCAA ' ` - • ` -
to
APPROXIMATE,TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $ +
(Including removal of all obstruction, materials, and debris, backfilling, com• .
paction and placing permanent resurfacing and/or, re placing improvements) -
1 x In consideration of the granting of this permit, the applicant hereby agrees to: 1'
d'I ndemnify;-defend and save the City, its authorized agents, officers, representatives and employees, harmless from and against any and all,,., '
.penalties,! liabilities or loss resulting fromclaimsor court action end arising out of any accident, loss or damage,to personsbr property
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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 twentyfour,(24) hours in advance of the time when work will be started. ,
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Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules and regulations of the City of'�
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La Quinta and to pay for any additional replacement necessary as,the-result of this work. '
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Signature of A'
A _ (n,, o ent 7
ame-QLA ( ease print) ,; t Business Address t Telephone No.' w
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C. LC.;', S Y t3ie � sl :So3
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Name of Contra for and Job Foreman ' ' Business Address Telephone No.
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Contractor's Ligense o. . , e e City Business license No.
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fir•` N�A•.
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Applicant's Insurance Company i. {, Policy Number
FEES: r Subdivision Improvement Permit — Class III
Public improvements: 3% o_ f estimated construction costs
Private improvements: 3%of estimated construction costs _
Minor Improvement Permit — Class IV: See attached schedule �' 2 7 7 4'
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Inspection Fee $ T `,
PERMIT VVA�fJLIDATION
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Permit Fee'!PERMIT
NO. '
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Penalty
Cash Deposit-Stirety Bond, .
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= ;DATE APPROVED'
if required
EXPIRATION DATE 2 S
TOTAL $
T• DATE ISSUED
Receipt No.
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Received by. ` Date - +
'♦' ' T Administrative Authority
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Recorded by
Telephone: (619) 777-7075
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