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3610, ... � �w -"1 ..-L' sir.'°s-',: A.. ti ..—..,__+�•tw lv� i� , -Y.. : 't.4'.` w�. .. �N. .�..i •. _ _ .. v ... .. � -. ,.-{�,_ _ `- _. ;4' 41! e� dd��r� fs�l� �� a1�1� i �� ds �r i�i•�i ice!=� �•�N4,��0r�.� �!� �l�r:Qi�®.�Y•r � ��r!!��^Y'�-011a.�a6�� rl� �� r �!•��M �►i!A � � NOTE: 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,IMAOVEMENTS and APPROVED SUBDIVISIONS r 1 Subdivision Improvement Permit — Class III DATE: Minor Improvement Permit Class IV LOCATION OF CONSTRUCTION (Street address or Description of Location) PURPOSE OF CONSTRUCTION DESCRIPTION OF CONSTRUCTION DIMENSION OF INSTALLATION OR REMOVAL `.. SIZE OF EXCAVATION, IF NEEDED Sketch (attach construction plans if appropriate) APPROXIMATE TIME WHEN WORK WILL BEGIN '� I APPROXIMATE TIME OF COMPLETION ESTIMATED CONSTRUCTION COST $ } (Including removal 'of all obstruction, materials, and debris, backfilling, com- paction and placiri g 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 withallapplicable City Ordinances, the, -terms and conditions of the permit and all applicable rules and regulations of the City of La Quinta and to w-e pay for any additional replacement neceessarssay y as the result of this work. ,- Signature of Applicant or Agent 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. Received by Date 38to PERMIT VALIDATION PERMIT NO. DATE APPROVED I EXPIRATION DATE DATE ISSUED By Administrative Authority Recorded by 11 Telephone: (760) 777-7075 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, pave and other like public works improvements in connection with MINOF, DATE: LOCATION OF CONSTRUCTION (Street address or Description of Location) PURPOSE OF CONSTRUCTION — DESCRIPTION OF CONSTRUCTION DIMENSION OF I,NSTALLATON OR REMOVAL SIZE OF EXCA TION, IF N DED APPROXIMATE T E WHEN WORK WILL BEGIN sidewalks, parking lots, sewers, water mains NTS and APPROVED SUBDIVISIONS Subdivision I mprovem4qt Permit — Class I II Minor Improve m t Permit Class IV Sketch (attach constructio plans if appropriate) APPROXIMATE TI OF C MPLETION \ ESTIMATED CONST UCTIO COST $ (Including removal of a obstr ction, materials, and debris, backfilling, om- paction and placing per anent esurfacing and'/or replacing improveme ts) _ In consideration of the g nting f this permit, the applicant hereby rees to: !%I Indemnify,.defend• and s ve the ' y, its authorized agenJ'ons epr sentatives and employees, harmless from and against any and all pen ies, liabilities or los resultin from claims or courar' ing out of any accident, loss or damage to persons or property happe g or occurring as proximate esult of any worder the permit granted pursuant to this application. Notify th%andt trative A hority at lea twenty-four advance of the time when work will be started. Comply wplicable Cit Ordinances, the s anof the permit and all applicable rules and regulations of the City of La Quintaay for any ditional replacement necessary as the result of this work. Name of Applicant (please print) Signature of Applicant or Agent Business Address Telephone No. Name of Contractor and Job Foreman Business Address Telephone No. Contrai ctor's License No. City Business License No. Applicant's Insurance Company Policy Number FEES: Subdivision Improvement Permit — Class I I I Public improvements: 3% of estimated construction costs Private improvements: 3% of estimated construction costs Minor. Improvement Permit — Class IV: See attached schedule N 0 3610 Inspection Fee $ I 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 By Administrative Authority Recorded by 11, Telephone: (760) 777-7075 r 1 NOTE: With proper validation this form:constitutes am,, 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 MINO�RA1VIPROVEMENTS and APPROVED SUBDIVISIONS ' DATE LOCATION OF CONSTRUCTION (Street address or Description of Location) PURPOSE OF CONSTRUCTION _ DESCRIPTION OF CONSTRUCTION DIMENSION OF INSTALLATION OR REMOVAL Subdivision Improvement Permit — Class II I Minor Improvement Permit Class IV Sketch (attach constructio 1 plans if appropriate) SIZE OF EXCAVATION, IF NE4EDED APPROXIMATE TIME WHEN WORK WILL BEGIN APPROXIMATE TI E OF COMPLETION ESTIMATED CONSTF�{UCTIOIN COST $ (Including removal of alll,I obstruction, materials, and debris, backfilling, �om- paction and placing per anent resurfacing and/or replacing improvements) In consideration of the g %nting of this permit, the applicant hereby agrees to: \ Indemnify, defend and�ve the ty, its authorized. agents, officers, reprlentatives and employees, harmless from and against any and all Pena�t es, liabilities or loss resulting from claims or court action and ar sing out of any accident, loss or damage to persons or property happening or occurring as proximate esult of any work undertakenu/nder the permit granted pursuant to this application. Notify the Administrative Authority at leas twenty-four (24) hours In advance of the time when work will be started. Comply with Inapplicable C y Ordinances, the to ms ar�dditions of the permit and all applicable rules and regulations of the City of La Quinta and to \fToranylitional replacement necessary as'the result of this work. Signature of Applicant or Agent 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` 3610 . 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 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 MINO,,PA'MPROVEIVIE` S and APPROVED SUBDIVISIONS DATE: LOCATION OF CONSTRUCTION (Street address or 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 constructio 1 plans if appropriate) � \ APPROXIMATE TIME OF COMPLETION � ESTIMATED CONST 1 CTIO-� COST $ rth (Including removal of a I obstruction, materials, and debris, backfilling, com- paction and placing per anent resurfacing and/or replacing improveme� ts) \\\\ J ` In consideration of the granting of this permit, the applicant hereby agrees to: \a Indemnify, defend• and s e e the C�i`y, its authorized agents, officers, representatives and `employees, harmless from and against any and all' pena ties, liabilities or lose 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 leas twenty-four (24) hours �ifi 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 f La Quinta and to,,pay for any additional replacement necessary as the result of this -work. Name of Applicant (please print) Name of Contractor and Job Foreman Contractor's License No. Signature of Applicant or Agent Business Address Business Address Telephone No: - Telephone 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 Y 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 By Administrative Authority Recorded by 7 :, Telephone: (760) 777-7075 r fir--�-^-r---y- r r,,-,.�..,{-•,;.. ;.�•q-';- ,.,.��- ..._.��' � at.. ,*`��- -�w�•a.:--.•,t.-"•y,'•.� .•.-�„�.:. �..� �•ac - �� , v ; Q•. I• s��:�.�a��oa.��r:�.•�rMs.��,�s�rM�..��uar�.rs+.►�r��oar..ua�r.f��.��as��..r r.�_�.�.w4s. NOTE: With proper validation this form constitutes an CITY OF LA OUINTA encroachment permit APPLICATION FOR PERMIT.* PUBLIC WORKS CONSTRUCTION '(ENCROACHMENT)., For the construction of public or private curbs, driveways, paven and other like public works improvements in connection with MINOB� DATE: LOCATION OF CONSTRUCTION (Street address or Description of Location) PURPOSE OF CONSTRUCTION _ DESCRIPTION OF CONSTRUCTION DIMENSION OF INSTALLATION OR REMOVAL SIZE OF EXCAVATION, IF NEEDED rents, sidewalks, parking lots, sewers, water mains I'NIPROVEMENTS and APPROVED.SUBDIVISIONS Subdivision Improvement. Permit —Class I11 Minor Improvement Permit Class IV Sketch (attach construction plans if appropriate) APPROXIMATE TIME WHEN(WORK WILL BEGIN APPROXIMATE TIME OF COMPLETION ESTIMATED CONSTRUCTION COST $ 1, (Including removal of all obstruction, materials, and debris, backfilling, com- action and placing �' k p p g permanentiresurfacing and/or replacing improvements). ' In consideration of the g a ting\of this permit, the applicant hereby g�grees.to: Indemnify, defend• and save the C•i,ty, its au thorized'agents, officers, reprrsentatives.and employees, harmless from and against any and all penalties,.liabilities or loss resultinglfrom claims or court action and a ising.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•EAdministrative Authority at least twenty-four (24) hours ileadvance of the time when work will be started. i 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 tozpay for any additional replacement necessary as the. result .of this.work. Name of Applicant (please print) Name of Contractor and Job Foreman Contractor's License No. Signature of Applicant or Agent Business Address Telephone No. Business Address. Telephone No. City Business License No. Applicant's Insurance Company Policy Number FEES: Subdivision Improvement Permit —Class III Public improvements: 3% of estimated construction costs Private improvements: 3% of estimated construction costs Minor Improvement Permit — Class IV: See attached schedule �s}y Inspection Fee $ PERMIT VALIDATION Permit Fee PERMIT NO. Penalty Cash Deposit -Surety Bond DATE APPROVED if required EXPIRATION DATE TOTAL: $ DATE ISSUED Receipt No. By' Received by Date Administrative Authority Recorded by Telephone: (760) 777-7075