3566----------------------------------------------------------------------.
NOTE:
With proper validation
this form constitutes an CITY OF LA QUINTA
encroachment permit
APPLICATION FOR PERMIT
IPUBLIC 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
i
i Subdivision Improvement Permit — Class III
DATE: `D Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION �/) �d /�- S Ao �E'7�1J '�
ifileAhbd 2e)2 m u p 5 (L bes-r- Ala b Va
(Street address or Description of Location)
PURPQSE C`OON�R CTI N �% etch (attach construction p ans if appropriate)
i J
i DESCRIPTION OF -CONSTRUCTION
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DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED may/
APPROXIMATE TIMF WHEN WORK WILL BEGIN
i //- 112 -7 -/ a -/ 00 - zao z.
! APPROXIMATE TIME COMPLETION
O/ESTIMATED CONSTRUCTION COST—'
(Including removal of all obstruction, materials, and debris, backfilling, com-
f 2,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
r i 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.
I• 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
iLe Quinta and to pay for any additional replacement necessary as the res t f this work.
1
Signature of Applicant or Agent
ao 7.3 •iv �w ii� p es� 6 0 9ij
Name of Applicant (please print) Business Address Q Qa a�Telephone No.
(aD
Name of Contractor and Job Foreman Business Address / Telephone No.
i
ontractor's License No. City Business License No.
lese,�7��5 Wes. �Q6�lo A-s 3 S�y��"YS�
I Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Class III .
Public improvements: 3% of'estimated construction costs
Private improvements: 3`Yo of estimated construction costs
Minor. Improvement Permit — Class IV: See attached schedule 3527
Inspection Fee $ PERMIT VALIDATION
Permit Fee
PERMIT NO.
35�1v
Penalty
Cash Deposit -Surety Bond ( DATE APPROVED
i if required' EXPIRATION DATE "��✓ ��
TOTAL: DATE ISSUED
Receipt No.
By
Received by Date Administrative Authority
Recorded by Telephone: (760) 777-7076,
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SPECIAL CONDITIONS --PERMIT NO. 3566
--- KINER/GOODSELL ---
L Streets and Parkways shall be kept clean. They shall be completely cleaned at the end of the event
and more frequently if required.
2. Pursuant to Section 14.16.110 of the La Quinta Municipal Code (Ordinance 10 § 1 (part), 1982),
Permittee shall assume responsibility for repair of any pavement damage to any public or private
street and for any damage to other City streets or facilities as a result of work performed under this
permit.
Pursuant to Section 14.16.250 of the La Quinta Municipal Code (Ordinance 10 § 1 (part), 1982),
advance warning signs and traffic control shall be installed and maintained in accordance with Cal
Trans Standards or the Work Area Traffic Control Handbook (WATCH Manual). It shall be the
Permittee's responsibility to appropriately detour and barricade this site. Refer to traffic control plans
provided by the City of La Quinta, Drawings A, 1,. and 3. Drawing 2 has been eliminated.
4. Should additional work, materials, or modifications of the work be required in order to meet City
standards, safety requirements, signage requirements, or to fit actual field conditions, the work shall
be performed by the Permittee as directed by and to the satisfaction of the City Engineer at no cost
to the City of La Quinta.
Special Conditions - Permit No. 3566 Page 1 of 1
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