486 (4)NOTE:
With proper validation -
- this form constitutes an CITY OF LA QUINTA
encroachment permit
APPLICATION -FOR PERMIT
PUBLIC- WORKS CONSTRUCTION (ENCROACHMENT)c�
For4he 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
- 4, •
Subdivision Improvement Permit — Class III
DATE: / �`� ® Minor Improvement Permit'Class 1V
/
LOCATION OF CONSTRUCTION ��� 07 �o
(Street address or Description of Location):
PURPOSE OF CONSTRUCTION — 114A Sketch (attach construction plans if appropriate)
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DESC PT OF C0 UCWI0 0
1+
DIMENSION OF INSTALLATION OR REMOVAL •�
SIZE OF EXCAVATION, IF NEEDED
APPROXIMATE TIME,WHEN WORK WILL BEGIN t
r i
APPROXIMATE TIME OF COMPLETION.2'*� �• y 5-V.
^"
ESTIMATED CONSTRUCTION COST $ ,
(Including removal :of.all�obstruction, materials, and `debris, backfilling, com-
paction and placing permanent resurfacing- and/or replacing improvements) f f
s
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.
S Comply with all applicable City Ordinances, the terms and conditions of the pe m>it and a 6licable rules a d regulations of the City of
La Quinta and to pay for any additional replacement necessary as the resultAjfiiis wgrl
S'gnature"pirgent �OL�X� i � ,
4OX
Name of Applicant (please. print) Business Address Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
Contractgr's License No. City Business License No.
Applicant's Insurance Company Policy Number
FEES: Subdivision Improvement Permit — Class I I I 1
Public improvements: 3%of estimated construction costs '
Private improvements:, 3% of estimated construction costs N� 4 0 6
Minor Improvement Permit — Class IV See attached schedule
1V Q t
Inspection Fee $
Permit Fee
Penalty -
Cash Deposit -Surety Bond
if required
TOTAL: $
Receipt No.
Received by Date
Recorded by
PERMIT VALIDATION
PERMIT NO.
DATE`APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
TELEPHONE: (619) 564-2246