451-ANOTE:
With proper validation
this form constitutes an CITY OF LA OUINTA
I 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 MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
Subdivision Improvement Permit — Class III
DATE: Minor Improvement Permit Class IV J
LOCATION OF CONSTRUCTION
(Street address or Description of t�P,Location
POSE OF CONSTRVC90N Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION Z —
D MENfS19,N OF_INJTAL4ATION 0,_ REMC _ f Ll / � /� �2T
SIZE OF EXCAVATION, IF NEEDED - -
11
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:
��i"✓�7P.G /lid. 4-5/ /•SSI��GC
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 tirge yOhen work will a started.
Comply with all applicable City Ordinances, the terms and conditions of the p r an applicable rul and regulations of the City of
La Quints and to pay for any additional replacement necessary as the result o is
0
C/
re
Name of Applicant (please print) Business Address Telephone No.
Name of Contra, for and Job Foreman Business Address Telephone No.
�9 471
Contr r' License No. City usiness License No.
tI
M-z
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 $ 11
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
//A
PERMIT VALIDATION
PERMIT NO. 15thZ4 "
DATE APPROVED .
EXPIRATION DATE
DATE ISSUED
By
Received by Date -
Recorded by
TELEPHONE: (619)564.2246
Administrative Authority