4361 (2)P'I
NOTE:
With proper validation
this form constitutes an
encroachment permits '
�r
For the. construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains
and other,'like public works improvements i,n connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
DATE: 03-16-05
LOCATION OF CONSTRUCTION TRACT
( Subdivision Improvement Permit — Class II I
\ Minor Improvement Permit Class IV
PALMS DRIVE
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION
INSTALL 1-8" .STOW- OUT appropriate)
Sketch (attach construction plans if a
CONNECTION & ABANDON A PORTION OF EXISTING WATER MAIN.
DESCRIPTION OF CONSTRUCTION WORK ORDER 1'110'429.9.
DISTRICT TO. OWN, OPERATE & MAINTAIN.
DIMENSION OF INSTALLATION OR REMOVAL AS NMED•
SIZE OF EXCAVATION, IF NEEDED AS NEEDED.
APPROXIMATE TIME WHEN WORK WILL BEGIN 03/05
APPROXIMATE TIME OF COMPLETION 0510_
ESTIMATED CONSTRUCTION COST $ A� D
(Including removal of all obstruction, materials, and deb is, bac filling, com-
paction and placing permanent resurfacing and/or replacing improvements)
In consideration of the granting. of this permit, the applicant hereby agrees to:
I'ndemnify,:defend and save the City, its authorized agents, officers, representatives and employees, harmless from and against any and all
penalties, I-iabilities 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
1rQAVM.i.A VATJY�V WA.TVR DISTRIC (DAVID MCGEE) P.O. Box 1058, Coachella, CA 92236 760-398-2651
Name of Applicant (please print) . Business Address Telephone No.
SAME AS ABOVE
NameofContractor 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 I I
Public improvements:. 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit — Class IV: See attached schedule
Inspection Fee $ IR
Permit Fee
Penalty
C sa h Deposit -Surety Bond
if required,
TOTAL .
Receipt No.
NO FEE
Received by Date
I!. 4361
PERMIT VALIDATION
PERMIT NO. 4361
DATE APPROVED 03-28-05
EXPIRATION DATE 121-756-06
DATE ISSSUED 3 -,Z
Administrative Authority
Recorded by 11Telephone: (760) 777-7075