3627NOTE:
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
Subdivision Improvement Permit — Class I I I
DATE: 2/48/02 Minor Improvement Permit Class IV
78-630 SAGUARO DRIVE
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
INSTALL AND NAINTAIN A ONE plans if appropriate)
ppropriate)
PURPOSE OF CONSTRUCTION Sketch (attach construction
INCH DOMESTIC WATER SMICH LINF.
DESCRIPTION OFCONSTRUCTION SEE ATTACHED SPECIAL .CONDITIONS
DIMENSION OF INSTALLATION OR REMOVAL
SIZE'OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF'COMPLETION NINETY DAYS
ESTIMATED CONSTRUCTION COST $ ' 1100.00
(Including removal of all obstruction, materials, and debris, backfilling, com-
paction .and placirig 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,
Signa"ture of Applicant or Agent
COACHELLA VALLEY WATER DISTRICT PO BOX 1058 COACHELLA CA 92236 76 98— 51
Name of Applicant (please print) Business Address Telephone No.
SSAM AS ABOVI?
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 III
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 0.00
Penalty
Cash Deposit-Surety'Bond
if required
TOTAL
Receipt No.
$ 0600
Received by Date
IV— 3627
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED 02/08/02
EXPIRATION DATE 5/31/02
DATE ISSUED /
BY 1•/'
r 6� Administrative Authority
I
Recorded by �, Telephone: (760) 777-7075
NOTE:
With proper validation
this formconsutute; an
eni:rcachment oermtt CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
For the construction of public or private '
and other like public works improvements in � � �ivewaM Pew. sidewalks. 19 IOU• saw=. water mains
connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
0 -2- Subdivision 1 mproventertt Permit -Class !11
LOCATION OF CONSTRUCTION _ `/ en S � Itnprotrematt Permit fit N
t -r„-- Ik�'v-n-c�
IStr•et a parts or Oescrtptma of Locattottl
PURPOSE OF CONSTRUCTION I M-TrALL AN & tnAINTA/IV A N E I •.� �•' Ski dt (attach construction plans if appropriate)
OESCRiPT10N OF CONSTRUCTION r L_ AIA -
DIMENSION OF INSTALLATION OR REMOVAL—
SIZE OF EXCAVATION IF NEEDED 3)14 �Ed
�
APPROXIMATE TIME WHEN WORK WILL BEGIN O ^ OZ FEB 0 7 200
APPROXIMATE TIME OF COMPLETION-�►811-CrY cge� HAYS PUBLIC W MKS
ESTIMATED CONSTRUCTION COSTS -I �OO.00
(Including removal of all obstruction. materials. and debris. badcftllirq. come �"` S t'GI W'-'�'�i'd'q
paction and placing permanent resurfacing and/or replat ng itnproing, co tl
In wnsideration of the granting of this permit, the appliont httnby agrees. to:
Ino•tnnNy. Ostend and "we the City. its authmuad •
Oenan�•s. ttaOtlut•s br tort restrpt from agents. oftteers, raoret mnum was wnplorsst. Itwmtou front art0 sq@u any
am i,
halia m ni datnts ar eOttet apron and artsttq owl
OI ally aaetdent. top or ttamag@ t0 persons or prou•n%
nq O► oceurrtr>g as a prosimat• resYlt at atttr wort waenssew wtdar the
Noaty the Adminntrsttre Authority, a1 least tw•m .1 Oerrnn WSMGO Owtttent to this appttcatwn.
r aw 1241 hours in advance of the ante attest weta wilt tw tuned.
Comotr min an applkaete Gtr Ordinances. the tarrtts and cortdtttonr of the psrmtt arid at1
La Quints ano to par for any additional replacement necessary
a00tiea0le ruin and regulationsof the Gtr o:
y q the
revolt d tftis twrh. COACHELLA VALLEY WATER DISTRICT . Signal Applittm or Agent X-5-0 �
Name of Applicant (please print) P • 0• Box 1058 COACHELIA, CA, 92236 398-2651
Business Ad an Telepnone No.
Name at Contractor and Job Foreman
Business Addr= Telephone No.
Contractor's License No.
City Business License No.
Applicant's insurance Comnany
Paltry Numtur
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