474-ANOTE:
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
DATE- `_ Z,3
LOCATIO OF CONSTRUCTION - 'eV615—
Subdivision Improvement Permit — Class II I
Milyr Improvement Permit Class IV
(Street address or Description of Location) I /
PURPOSE CONSTRICTION Sketch (attach construction plans if appropriate)
LLATION 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:
71�
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.
Notity the Administrative Authority at least twenty-four (24) hours in advance of the time work will be started.
Comply with all applicable City Ordinances, the terms and conditions of the permit aa�f'+d p iwble rules a egulations of the City of
La Quints and to pay for any additional replacement necessary as the result 0" jwo
Signs e o)XAljplica
Name of Applicant lea rirt0 Business Address Telephone
Name of Contractor and Job Foreman Business Address Telephone No.
. l
Contr or's icknse 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 $
I)
Permit Fee /0
Penalty
Cash Deposit -Surety Bond
if required
TOTAL:
Receipt No.
8 f2�2
Received by Date
Recorded by
PERMIT
VALIDATION
PERMIT NO. `Z 75L22
DATE APPROVED
EXPIRATION DATE
DATE ISSUED )
B y cli
Administrative Authority
TELEPHONE: (619) 5 4.2246
Isolation Area Affected
Pressure District Affected•
. Business. District_ Affected
Supply Line Affected
Valve(s) Required
Reviewed By: (�C )!lW\t 1 tI�
C.P..Reviewed By: ���• `�����
'
Yes ❑ No l
/
Yes. ❑ No C>a
Yes O No l
Yes ❑ No
Yes ❑ No
/,f Q.
7!`JV�-+ !v
`v `
P
INSTALL MAIN WITH AT LEAST �'�
y/ +
COVER BELOW �" r T�,V V
TOTAL FEET INST'D.
TOTAL FEET RETIRED
-
COUNTY � • 1
�� i T�
DISTRICT
TRACT S
RETIREMENT
REASON-
PERMIT -ISSUED -BY
PERMIT. NO.
�A♦
DATE MOVED _ DATE MOVED DATE OF -
ON JOB OFF JOB OPER.
CREW FOREMAN
COMPANY
PLANNED BY
�/LL'STAKED
:
NO. \ pJ'
ATLAS i ly
NO... _
`YEAR C.P.
- INSTALLED
OPER. 20%OROVER Q
AT LESS THAN 20% ,• S.M.Y.S.
❑
STAKING REQ D.
NO STAKES NEEDED
COMPANY. FACILITY: SO. CAL. �,- P.L.S. Q
_
`'r1 .:.�.
1tV�N ^-�• 1f DIVISION
W.O.r ORG.. . .
! �� CODE
REV 1 EW ED BY
1 rf�y F�
J
r
CATHODICALY I
YES .0 NO,.
PROTECTED .,
DISTRICTS ERVISOR -