3576I
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
DATE
LOCATION OF CONSTRUCTION
Subdivision Improvement Permit— Class III
Minor Improvement Permit Class IV
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
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, to ama persons or property
happening or occurring as a proximate result of any work undertaken under the permit grante ursuant to this applica
Notify the Administrative Authority at least twenty-four (24) hours in advance of the time hen 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 'ty of
La Quinta and to pay for any additional replacement necessary as the result of this work. N
Name of Applicant (please print)
Name of Contractor and Job Foreman
Contractor's License No.
Signature of\Npplicant or
Busin4s Address \ \ Telephone No.
Business )Address \ \ T
Business L
Applicant's Insurance Company \ ( 1 I Policy Number
FEES: Subdivision Improvement Nermit — (
Public improvements: 3° of estin
Private improvements: 3% of estir
Minor. Improvement Permit — lass
Inspection Fee $
Permit Fee _
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No
Received by Date
�d constructlo osts
ed construction co
See attached schedule
3576
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
Recorded by
Telephone: (760) 777-7075
MM
NOTE: '
W th proper validation
t his 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: ;;, ` Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION
DESCRIPTION OF CONSTRUCTION t
4
DIMENSION OF INSTALLATION OR REMOVAL t
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
Sketch (attach construction plans if appropriate)
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: _"```-^•�r..
Indemnify, de?en6 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 cm:rt action and arising out of any accident, lo3srordama a —tom ersons or property
happening or occurring as a proximate result of any work undertaken under the permit granted to this appli�o ..\
Notify the Administrative Authority at least twenty-fou- (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
Name of Applicant (please print)
Business Address
\
Telephone N/
Name of Contractor and Job Foreman
I Business Address
Telet3hone4o.
Contractor's License No.
Business L
Applicant's Insurance Company \ I 1 I Policy Number
FEES: Subdivision Improvement Permit — Class II I
Public improvements: 3%of estimated constructio costs
Private improvements: 3% of estimalted construction,costs-
Minor Improvement Permit - Class IV See attached schedule
Inspection Fee $ \ '
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $
Receipt No.
Received by Date
Recorded by
3576
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
Telephone: (760) 777-7075
NA,
/With proper validation
s�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 III
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
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, I s-o -damage-tompersons or property
happening or occurring as a proximate result of any work undertaken under the permit grant when
to this appli a "' .
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 ity of
La Quinta and to pay for any additional replacement necessary as the result of this work.
Name of Applicant (please print)
Signature of�Applicant
� r
Business Address
Telephone No.
Name of Contractor and Job Foreman I Business Address \ \ Telephon /No.
Contractor's License No. Cit Business Lice.\ a No-""'
Applicant's Insurance Company \ I , + Policy Number
FEES: Subdivision Improvement Permit — CI ss I I I 1
Public improvements: 3% of estimated constructio costs
Private improvements: 3% f estimal�:See
ed construction costs
Minor. Improvement Permit—l�Mass attached schedule 3576
Inspection Fee $ `� II PERMIT VALIDATION
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $
Receipt No
Received by
Date
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
Administrative Authority
Recorded by
Telephone: (760) 777-7075
i
NOTE:
10Ath 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 II I
DATE: Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
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, lossror 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.
l \\\
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. 1
" 1 4
1 Signature of�Applicant or�AAgent
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 I , Policy Number
FEES: Subdivision Improvement, Permit — CI �ss I II
Public improvements: 3% of estimated construction osts
Private improvements: 3°/0 of estimalted construction costs
Minor. Improvement Permit Al lass IVi See attached schedule
Inspection Fee PERMIT VALIDATION
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $
Receipt No.
Received by Date
Recorded by
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
.. DATE ISSUED
By
Administrative Authority
Telephone: (760) 777-7075
�1
NgTE:
'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
LOCATION OF CONSTRUCTION
(Street address of Description of Location)
PURPOSE OF CONSTRUCTION
DESCRIPTION OF CONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
Subdivision Improvement Permit — Class III
Minor Improvement Permit Class IV
Sketch (attach construction plans if appropriate)
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $
(Including removal of all obstruction, materials, and debris, backfilling, com-
paction and placing permanent resurfacing arid/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`dainage•to.persons or property
happening or occurring as a proximate result of any work undertaken under the permit granted�p suant to this application._
Notify the Administrative Authority at least twenty-four (24) hours in advance of the time when work will be started.
t
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.
1
Signature of Applicant or Agent I
Name of Applicant (please print) f� Business Address Telephone No.
1
Name of Contractor and Job Foreman Business Address \ Telephone,No.
Contractor's License No. Cit'y Business License No:'"
Applicant's Insurance Company \ ( I Policy Number
FEES: Subdivision Improvement Permit — Class III
Public improvements: 3% of estima fed construct ion, costs
Private improvements: 3%&f 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.
Received by Date
570
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
Recorded by
Telephone: (760) 777-7075