3814NOTE:
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 II
DATE: January 10, 2003 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION The Gas Company hereby applies for a blanket to do routine
main and service maintenance of gas facilities within the city limits of
(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 j
ESTIMALTEl ."CON'ST-RUCTION 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,.d&end: and save the City, its authorized agents, officers, representatives and employees, harmless from and against any and all
,g@penaltie's;,liabilities or loss resulting from claims or court action and arising out of any accident, loss or damage to persons or property
happenind'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.
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 I II
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit - Class IV: See attached schedule
Inspection Fee, $ �I
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
r . TOTAL: $
Receipt No.
Received by Date
Recorded by
N2 3814
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
Telephone: (760) 777-7075
• 1
r .
.:f_ . � '. �. ..
— � -
-NOTE:
With proper validation
thi" form constitutes an
encroachment permit
-CITY'OF LA' QUINTA"
APPLICATION, FOR PERMIT -
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
OF
For the construction of public or private curbs, driveways, pavements, sidewalks, - y parking lots, sewers, water mains.
and•other•like-public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS.
Subdivision Improvement Permit — Class II
DATE: 'January 10, . �003 Minor Improvement Permit Cla'ss-IV•
LOCATION OF CONSTRUCTION The ' Gas Company hereby applies for ., a.. blanket to .do routine
main and service maintenance of gas facilities within the city limits of
(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, 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 JI?e 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 this7,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 Irriproyement Permit — Class I I
Public improvements: "3% of estimated construction costs
'Private improvements: 3% of estimated construction costs --
Minor. Improvement Permit — Class IV: See attached schedule r
.:3814
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 f Administrative Authority
Recorde'd by Telephone: (760) 777-7075.
_ _ __ � _ ..._-•- -- _ .�,� •�Ntt: � i�i �Ijfi'j,{r,.lyl.l, ����� • - '.------. --.. _.—.—.—.—
VW
NOTE: /
With pro per.validation.
`�w.. 2
this form constitutes an
encroachment permit
" CITY OF LA QUINTA'
_ APPLICATION. FOR PERMIT.. .
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)��
OF fRg�
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 an&APPROVED SUBDIVISIONS
Subdivlsion,lmprovement Permit—�Classall
DATE: January, 10'i' 003 ` Minor improvement Permit Class IV
LOCATION OF CONSTRUCTION The Gass. Co 'any hereby "app�ie� for" a.'•b.l� lc� to •da, zyutine
maid and eeryiee main,Ce ance of gas fa,diliti.e.s : within.. the
(Street address or Description. of Location)
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)
DESCRIPTION O ;CONSTRUCTION.
DIMENSION OF INSTALLATION.OR REMOVAL
.SdE:.OF`EXCAVATION,, IF NEEDED
APPROX:IMATE.TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME'OF COMPLETION
ESTIMATED CON STRUCTION.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'applicarnt.hereby agrees to: .
Indemnify,:defend and save the City, its authorized agents, officers,, representatives and employees, harmlewfrom and against any and all t
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.
Signature of Applicant or Agent
Name'.of Applicant, (please print); `. Business Address Telephone No.
Name'of Contractor and Job Foreman „ Business Address 'Telephone No... _
Contracto'r's License:No. City Business License No:'
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit —Class III'
Public improvements:. 36/o of'estimated construction costs
Private improvements:3% of estimated construction costs
Minor' Improvement Permit — Class IV: See attached schedule
3;0 A
-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
"-� ♦ ' — - - v .'�!k_ _ _ _ _ ._ .,- T — ,i ; � : Y*i<�i :�`�," t�?..n '- ly�y`�kTr.�`�^.'';Li"aryY,::V.— �.._ — _ — — -.-, — — — _ — . — __, . _ -
-
NOTE':.
Wrth.prope'r validation .. 2
this form constitutes an
;.. CITY.OF LA QUINTA.
• encroachment permit �
APPLICATION. FOR'PERMIT -
'" PUBLIC WORKS::CONSTRUCTION (ENCROACHMENT)��.
?ilOF 1 A$9
;. 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 II
DATE:," jawimrY ' 10 2003 Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION e 0" C gtaz iy hereby applies for a blaaket :to do routin
aalfia and sarriai maint�cnahce of : py factli>rle a within the cjty • ljait* ;of
(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
' APPROX•IMATE'TIME WHEN WORK WILL BEGIN
"r '-APPROXIbATE•TI.ME OF COMPLETION
c: TED EST!=CONSTRUCTION COST $
(1nc,Uding 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 1. 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 ail.applicable City Ordinances, the terms and conditions.of the permit and all applicable rules and regulations of the,_Ciiy of
La Quinta and 'to pay for any additional replacement necessary as the result .of.this'twork.
Signature of Applicant or Agent
a
Name of Applicant (please print) Business Address Telephone 'No.
Name of Contractorand Job Foreman Business Address Telephone No.
Contractor's•License No'. City'Business License No.
s. Applicant's Insurance Company Policy. Number
FEES: Subdivision Improvement Permit — Class I I,I
Public improvements: 3% of estimated construction costs
'Private improvements:,3%o of estimated construction costs.
Minor ..Improvement Permit — Class IV: See attached schedule ,
Inspection Fee $ PERMIT. VALIDATION
Permit Fee _ PERMIT NO.
Penalty
Cash Deposit -Surety Bond DATE APPROVED
if'required. EXPIRATION DATE
TOTAL: $ a...�r
DATE' ISSUED
Receipt No.. By
y
Received by Date Administrative Authority.
Recorded by Telephone: (760) 777-7075
NOTE:.
With proper validation
this form constitutes an
encroachment permit
CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)'
bM
s
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
U
Subdivision Improvement Permit'— Class I I I
DATE: + Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION Tbta Us Cocpoay I' or by aipPXion for a blaukat to too rbUt,1144
tofu and, t orrice maint4nanee of Mao fac%litl o witbiaa ha city liatto of `
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Sketch (attach construction plans if appropriate)
DESCR•IPTION'OFFCONSTRUCTION
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME WHEN WORK WILL BEGIN' '
>APPROXIMA�TE TIME OF COMPLETION J !
..".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"br loss resulting from claims or court action and arising out of any accident, loss or damage to persons or property .
happening or occurrin as a proximate result of an work undertaken under the ? p, g g p y 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
La Quinta and to pay for any additional replacement necessary as the result of this work.
Signature of Applicant or Agent
Name of Applicant (please print) Business Address Telephone No.
Name of Coritractor and.Job Foreman Business Address u;, Telephone No.
Contractor's License -No. City Business License No.
Applicant's Insurance Company Policy Number
k
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
IN*
Inspection Fee $ PERMIT VALIDATION
Permit Fee• • ' ,: PERMIT NO.
Penalty
"„ DATE APPROVED
Cash Dep9slt-Surety Bond
if required ,• EXPIRATION DATE
TOTAL: $ DATE ISSUED
Receipt No.
l By
Received by -Date Administrative.Authority .
Recorded. by Telephone: (760) 777-7075