3790 (2)NOTE: Owl
With proper validation' • 1,l Q
this form constitutes an CITY OF Lk QUINTA
encroachment permit . • i . _
' APPLICATION' FOR PERMIT . $
.°PUBLIC WORKS ONST CTION (ENCROACHMENT).
c� , .'"„�• w5w��
For the construction of public or: r a e cu�+ driveways; pavements, sidewalks, parking lots, sewers, water mains
a and other Pike public wo improvp(�•)'\e is in co nection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
f �•, Subdivision,lmprovement Permit - Class I I I
DATE: ! 1 ''� i -7p Minor Improvement Permit Class IV
LOCA ION OF -CO STRUCTI' ►&4 / �Z� ` J0G 1
t
(Street address or Descri tion of :Location) ,, • '
PURPOSE OF CONSTRUCTION / Sketch (attach construction plans•if appropriate) .
DESCRIP.TION'OF CONSTRUCTION (
• n
D ENSION OF INSTA)_LATION O� RE V L, D ��'
SIZE OF EXCAVATION, IF NEEDED �i
. /,
APPROXIMATE TIME WHEN WORK WILL BEGIN
' APPROXIMATE TIME OF COMP.LETION
• 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 an /save the City„ its authorized agents, officers; representatives and employees, harmless from and against any and all
penalties, liabilities o loss ,resulting from claims or court action and arising out of any accident, loss or damage to persons or property
happening. or occurri g as a proximate result of any work undertaken under the permit granted,pursuant to this application.
Notify the'Adminis ative Authority at least twenty-four (24) ,hours in •advance of the time when work will be started.
Comply with'all a licable'City Ordinances, -the terms' and, conditions the permit and all applicable rules and regulations of the City of
La Quints and to ay' for any additional replacement necessary's he result of this wo i
t Signature off Applicant or Agent
7�
�Z- 760- Z7% g�! . .
Name of Applicant ('.lease rint) " Busine Address Telephone No:
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Name of Contractor n Job'Foreman Business Address Telephone No.
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Contractor's Licensed No. City Business License No.
Applicant's lnsurar�ce Company • Policy Number. '
j 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 9 - '
N -3790
Inspection Fee $ • PERMIT. VALIDATION
Permit Fee PERMIT NO.
µ , 'Penalty
+. DATE APPROVED
Cash Deposit -Surety Bond
if required ,
EXPIRATION DATE
` TOTAL: $ DATE ISSUED
Receipt No. "
4 By
Received by Date f Administrative Authority
.'Recorded by - Telephone:'(760) 777-7075 '