3349'NOTE
With proper validation
this form constitutes an
CITY OF LA QUINTA
encroachment permit
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
Subdivision Improvement Permit — Class I I I
DATE: 12/3/00 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION 51--440 Ave. Mendoza & Ave. Montezuma
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Repair water service Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION See Attached Special Conditions
DIMENSION OF INSTALLATION OR REMOVAL
4' x 4' bell hole
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN 12/3/00
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)
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 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 permit 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
CVWD P.O. Box 1051 39R-2651
Name of Applicant (please print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No.
City Business License No.
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Class 111
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction'costs
Minor. Improvement Permit — Class IV: See attached schedule
Inspection Fee
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
$
-0-
$ —0—
Received by Date
Recorded by
3349
PERMIT VALIDATION
PERMIT NO. 3349
DATE APPROVED 12/1/00
EXPIRATION DATE 12/30000
DATE ISSUED /12/4100
gy ��f a J2.
�-� Administrative Authority
Telephone: (760) 777-7075 /
With proper validatlon
this form constitutes an
eneiroacnntent 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 SUBDI'JISIONS
DATE:— Z— 3 ' 00 Subdivision Improvement Permit — Class III
S`/ — y y0 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
/�I�G oni-:�✓/7a 2.4,falyfr MU•t/T�Zyrdlr9
IStraet address or OesNlptlon of Location)
PURPOSE OF CONSTRUCTION
Si2(//G-� (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION -
DIMENSION O eINS LATION OR REMOVAL
I ra i? 6-1o 1,1—
SIZE OF EXCAVATION. IF NEEDED
APPROXIMATE TIME WHErj WORK WILL BEGIN LL- 7 -u U
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST S
(Including removal of all obstruction, materials, and debris, baekfillingr Com• Paction and placing permanent resurfacing and/or replacing Improvements)
in consideration of the granting of this permit, the applicant hereby agrees to:
Inde
Pe""'Inns, dahrad and saw the City. fit claims
' agents. offiem' rephs"ritativaa and employees, harmless from and against any and all
happens , la f Occurring
at lop retuning trOm clUma or court atllon and alts.ng out of any aM"kinl, loci or
flapOanarq to oeeurrarae as • proeamate result of any work undartakan undo, the permit granted pursuant tee t� eppllut On. " to persons or Properey
Nouty theAdminntntava Authority as lent twenty-four 1241 hours In sdwnce of the time when work wail be started.
Comply wrath all applarabla C-li Ordinances. the terms and conditions of the permit and all applacabie rules and regulations of the City of
Le Ouinta and to pay for any additional replacement necessary so the result of this work.
k/
Name of Applicant'
print)
Applicant or Agent
Telephone No.
Name of Contractor and Job Foremen
Business Address Telephone No.
Contractor's Licansa No.
City Business License No.
Applicant's Insurance Company FrEN. L.IAQILITy
Policy Number
FEES: Subdivision Improvement Permit —Class III
Business Address
Public improvements: 3% of estimated construction costs
Private Improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee
Permit Fee
Penalty
Cash Oeposlt•Surety Bond
if required
TOTAL. S
Recelot No.
Received by
Jate _�
PERMIT VALIDATION
PERMIT NO. —
33;
Y2
DATE APPROVED
�Ti
EXPIRATION DATE
DATE ISSUED
111410
a
By
�orninistrative Au:-3r!•,