486 (5)K
NOTE:
With proper validation
this form constitutes an
encroachment permit
It
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: 5- �—
LOCATION OF CONSTRUCTION ,
(Street address or Description of Locatio /� n
PURPOSE OF CONSTRUCTION
DESCAR!PTI0jN OF COJVSTRUCTIiON e
V
DIW IO'OR.REMOANT�
SIZE OF EY�y-CAVATION,!IF. EEDED �6
.(QX/ Sn ✓Ln Sy� 5,
Subdivision Improvement Permit — Class I II
I Minors Inirovement Permit Class IV
w- ,Sev, / tt
Sketch (attach construction plans if appropriate)
APPROXIMATC41ME WHEN WORK WILL BEGIN
APPROXIMATE TIME OF COMPLETION 0
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 tTpert and Iplicable rules d regulations of the City of
La Quinta and to pay for any,additional replacement necessary as the resis w f_
Signatur o Appli or A ent
Name of Applicant (please print) Busines ddress Telephone No.
Name of Contractor and -Job Foreman Business Address Telephone No.
Contractor's, License No. City Business License No.
iesxt/_
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 $
Permit Fee
5
Penalty
Cash Deposit -Surety Bond
if required
TOTAL: $
Receipt No.
Received by Date
Recorded by
N° 486
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
TELEPHONE: (619) 564-2246 '