486 (2)NOTE:
With proper validation
this form constitutes an CITY OF LA QUINTA
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 II I
DATE: '` _ ` Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION
(Street address or Description of Location)
PURP,QSE OF C�ISTRUCTIONy��'eyE � d Sketch (attach construction plans if appropriate)
DESCRIPTION OF CO
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED,
APPROXIMATE TIME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION C'
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. when work, will be started.
Comply with all applicable City Ordinances, the terms and conditions of the permit and I a licable rul d regulations of the City of
La Quinta and to pay for any additional replacement necessary as the result is vv
gna ure A I' t or e t
Name of cant (please print) . y Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
�g"/2
Co I cto j3 License No. 1 / t ' City Business License No.
Applicant's Insurance Company C r Policy Number
FEES: Subdivision Improvement Permit — Class III
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs 0 4 86
Minor Improvement Permit — Class IV: See attached schedule j�
Inspection'Fee $ PERMIT VALIDATION
Permit Fee PERMIT NO.
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $
Receipt No.
Received by
Date
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
Recorded by
TELEPHONE: (619) 564-2246