486APPLICATION` 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
r
/: _ r� Subdivision Improvement Permit — Class III
DATE: c�'� U �rL Minor Improvement PermitClass IV .
LOCATION OF CONSTRUCTION �� �fr
(Street address or Description of Location)
PU S CONSTRUCTION �'OSketch (attach construction plans if � � C appropriate)
DE CR)PTIOAI,OF CONSTRUCT ON.
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 the Administrative Authority at least twenty-four (24) hours in advance of the time whe work will. be started..
Comply with all applicable City Ordinances, the terms and conditions of'the permit a d all � is le rules and regulations of the City of
La Ouinta and to pay for any additional replacement necessary as.the result of i work:
J9
Name of Applicant (please. print)
Signature of ApOli
Business Adtkfess 4
nt
�C 3
Telephone No..
Name of Contractor and Job Foreman Business Address Telephone No. `
Con ctor'� License No / / City Business Licen a No.
Applicant's Insurance Company
FEES: Subdivision Improvement Permit — Class II I
Public improvement s:�3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit
?,—�Class IV: See attached schedule
I Inspection Fee $ "
Permit Fee
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $
Receipt No.
Received by Date
y' Recorded by
N
N° -486
r PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
:Administrative Authority
TELEPHONE: (619) 564-2246